On-call Workload Research Articles

Letter: On-Call Workload Differences in Neurosurgery: Resident Call "Weather" and a Departure From Colored Cloud Labels.

Letter: On-Call Workload Differences in Neurosurgery: Resident Call "Weather" and a Departure From Colored Cloud Labels.

In Reply: On-Call Workload Differences in Neurosurgery: Resident Call "Weather" and a Departure From Colored Cloud Labels.

In Reply: On-Call Workload Differences in Neurosurgery: Resident Call "Weather" and a Departure From Colored Cloud Labels.

WP4.2 - Covid positivity: the pandemic surgical referral telephone triage legacy lives on

Abstract Introduction Covid restrictions provided opportunities for novel approaches to patient assessment. Innovative telephone triage of surgical referrals at Great Western Hospital, a UK District General Hospital, resulted in reduction in those patients reviewed and discharged the same day from 56% to 23.6%. Furthermore, 28.4% of admissions were avoided by triage. This novel work was adapted for the Ambulatory Emergency Care (AEC) department of Yeovil District Hospital, in response to exponential increases in Primary Care and Emergency Department referrals. Aims To develop a telephone triage system to get the right patient to the right place at the right time, reviewed by the right team. Methods Over the two-week study period (18/9–29/9/2023) a dedicated triage telephone line enabled a discussion between referring clinician and an experienced surgeon. Four outcomes were offered:AdviceOutpatient review within 1 weekHot clinic review within 24-48 hoursSame-day review by the on-call team Prospective referral data (18/9–29/9/2023) and retrospective non-triage data (1/9–14/9/2023) were gathered. Triage effects were measured by outcome comparison with non-triage data. Results A total of 193 patients were discussed. 48% were Emergency Department referrals, 25% from General Practitioners. Same-day reviews reduced by 35%. Overall, the on-call workload decreased by 68%. Return to AEC for review reduced by 99%. Reduction in average time spent by patients in AEC from 6.9 to 1.29 hours, saved up to 6 bed-days per day and facilitated significant cost savings. Conclusions Novel approaches can be cost effective and positively impact patient care.

On-Call Workload Differences in Neurosurgery: Resident Call "Weather" and a Departure from Colored Cloud Labels.

Labeling residents as "black" or "white" clouds based on perceived or presumed workloads is a timeworn custom across medical training and practice. Previous studies examining whether such perceptions align with objective workload patterns have offered conflicting results. We assessed whether such peer-assigned labels were associated with between-resident differences in objective, on-call workload metrics in three classes of neurosurgery junior residents. In doing so, we introduce more inclusive terminology for perceived differences in workload metrics. Residents were instructed to complete surveys to identify "sunny", "neutral", and "stormy" residents, reflecting least to greatest perceived workloads, of their respective classes. We retrospectively reviewed department and electronic medical records to record volume of on-call work over the first 4 months of each resident's 2nd postgraduate academic year. Inter-rater agreement of survey responses was measured using Fleiss' kappa. All statistical analyses were performed with a significance threshold of P < .05. Across all classes, there was strong inter-rater agreement in the identification of stormy and sunny residents (Kappa = 1.000, P = .003). While differences in on-call workload measures existed within each class, "weather" designations did not consistently reflect these differences. There were significant intraclass differences in per shift consult volume in two classes ( P = .035 and P = .009); however, consult volume corresponded to a resident's weather designations in only one class. Stormy residents generally saw more emergencies and, in 2 classes, performed more bedside procedures than their peers. Significant differences in objective on-call experience exist between junior neurosurgery residents. Self- and peer-assigned weather labels did not consistently align with a pattern of these differences, suggesting that other factors contribute to such labels.

Afterhours patient phone calls: a quality improvement study.

Patient phone calls over 82 shifts were documented from May 2020 to January 2021 by on-call orthopedic residents. The length, nature, and associated attending physician of each call were recorded, as well as whether the call resulted in an emergency department visit. The nature of each phone call was categorized into one of 12 categories. An urban, tertiary care academic institution in the Midwest, USA. All orthopedic residents on-call during this period logged the phone calls that they received and related relevant data. Orthopedic surgery residents took an average of 8.6 patient phone calls (average 53.3 total minutes) per shift. The most common reasons for the phone calls were pain, prescription, and pharmacy concerns, which together represented over half of the calls. Twenty-one (4.1%) phone calls resulted in an emergency department visit. Concerns about pain and prescriptions were among the most common reasons for patient phone calls. This information points to opportunities for interventions that could help guide how postoperative pain is discussed with patients, including providing patients with reasonable expectations for pain control, function, and tools for better self-efficacy. This approach could not only enhance patient care but also decrease resident on-call workload and improve resident wellbeing.

Burnout, stress and intentions to leave work in New Zealand psychiatrists; a mixed methods cross sectional study

BackgroundDemand for mental health services in New Zealand and internationally is growing. Little is known about how psychiatrists are faring in this environment. This study aimed to investigate wellbeing of psychiatrists working in the public health system in New Zealand, identify the main risk factors for work-related stress, gauge perceptions of how workload has changed over time, assess job satisfaction and whether individuals intend or desire to leave their work.MethodsPsychiatrists working in New Zealand who were also members of the Association of Salaried Medical Specialists were invited to participate in an online survey. Main outcome measures were degree of burnout and stress experienced at work. Supplementary measures included perceived workplace demands and levels of support. Predictor variables included perceptions of changes to workloads over time, degree of job satisfaction and intentions to leave work. Logistic regression assessed characteristics associated with burnout and job satisfaction as well as intentions to leave work. Free text comments were analysed thematically alongside quantitative trends.Results368/526 responded (70% response rate). 34.6% met the criteria for burnout and 35.3% scored with high work stress. There were no significant patterns of association with demographic variables but significant correlation with all but one predictor variable; having experienced a change to the demands of the on-call workload. 45% agreed they would leave their current job if able and 87% disagreed that they are working in a well-resourced mental health service. Respondents emphasised the impact of growing workloads and expressed concerns about their ability to provide optimal care in these circumstances.ConclusionsHigh burnout appears to affect one in three psychiatrists in New Zealand. Many attribute their feelings of burnout to demand for their services. These findings may assist with better workforce planning for psychiatry and emphasises potential consequences of demand for and poor resourcing of mental health services for the retention and wellbeing of doctors in psychiatry worldwide.

Ophthalmology on Call: Evaluating the Volume, Urgency, and Type of Pages Received at a Tertiary Care Center.

Background: A significant proportion of on-call resident workload is related to answering and managing pages. Ophthalmology residents see high volumes of patients on call, but little is known about the profile of pages they receive. The objective of this study is to characterize the volume, type, and urgency of pages received by the ophthalmology on-call service.Methods: A retrospective review of on-call pager log sheets and patient charts was performed at a single academic institution. Data were collected from July to December 2019, sampling the first seven days of each month. Data collected for each page included date/time of day, source, and primary concern. For each page leading to a patient encounter, time from page to patient assessment, patient demographics, and final diagnosis were recorded. Continuous variables were reported as mean values, whereas categorical variables were presented as percentages. A two-sample t-test and single-factor analysis of variance were employed.Results: Over 42 days, 1108 pages were received. Over half of these calls required patient assessment, 71% of which were seen the same day. On average, 26 pages were received in 24 hours. Daytime weekday hours were significantly more busy than weekday nights or weekends (p<0.001). Patients and the emergency department each accounted for almost one-third of calls received. Retina- and cornea-related consults were most common.Conclusions: Pager volumes in ophthalmology are high and on-call patient volumes are rising. Answering pages increases the on-call resident’s workload and has a negative impact on clinic flow. These data can be used to inform resident curriculum development, hospital system changes, patient education regarding appropriate paging, and medical school teaching.

Trend in radiologist workload compared to number of admissions in the emergency department

IntroductionRecent years have shown an increase in radiologists’ workload, both during regular working hours and during on-call. We aimed to quantify the 8-year trend in on-call workload in a large tertiary academic medical center, and to compare the workload growth rate to emergency department (ED) visits growth rate during the same period. MethodsThe number of computed tomography (CT) studies during on-call hours (weekdays between 3.00 p.m. and 8.00 a.m., and weekends) between 2012 and 2019 was extracted from our hospital’s Radiologic Information System. To estimate the on-call workload, all studies were converted to relative value units (RVUs) using the US Medicare physician reimbursement tables. The Kendall’s tau b test was used to assess the temporal trend. ResultsOverall, on-call CT RVUs increased by 52% (Kendall’s tau b = 0.776, p = 0.001) while ED visit rate grew by 23% with a weaker correlation coefficient (Kendall’s tau b = 0.323, p = 0.009). RVUs of brain CT, the most prevalent examination type, increased by 33%, while abdominal CT, the second most prevalent examination, increased by 70%. Thoracic-lumbar spine CT examinations increased by 1375% and head and neck CT angiography examinations (stroke protocol and CT-Venography) grew by 287%. ConclusionsRadiologists’ on-call workload more than doubled the growth rate of ED visits over an 8-year period. Radiologists, radiographers and on-call ED workforce should be adjusted to accommodate these evolving changes to enhance quality and safety of patient care and to avoid caregivers’ burnout.

Analyzing Anatomic Pathology On-Call Summaries to Improve Resident Education.

Pathology on-call experiences help prepare trainees for successful transition from residency to independent practice, and as such are an integral component of training. However, few data exist on anatomic pathology resident on-call workload and experience. To obtain an overall picture of the anatomic pathology on-call experience to inform and improve resident education. Retrospective and prospective review of daily anatomic pathology on-call summaries from July 2016 to June 2020. During the first 2 years of the study (ie, retrospective portion), only 19% of on-call summaries (138 of 730) were available for review. After interventions, the on-call summary submission rate jumped to 98% (716 of 731). After-hours calls were most frequent on weekdays from 5 to 8 pm. The most frequent requests were for frozen sections (55%; 619 of 1125 calls), inquiries regarding disposition of fresh placentas (13%; 148 of 1125 calls), and inquiries regarding disposition of various other specimens (6%; 68 of 1125 calls). After-hours frozen section requests were most frequent for gynecologic and head and neck specimens. Notably, a significant number of after-hours calls were recurring preanalytic issues amenable to system-level improvements. We were able to eliminate the most common of these recurring preanalytic calls with stepwise interventions. To our knowledge, this is the first study analyzing the anatomic pathology resident on-call experience. In addition to obtaining a broad overview of the residents' clinical exposure on this service, we identified and resolved issues critical to optimal patient care (eg, inconsistent "patient hand-off") and improved the resident on-call experience (eg, fewer preanalytic calls increased resident time for other clinical, educational, or wellness activities).

Workload for radiologists during on-call hours: dramatic increase in the past 15\xa0years

BackgroundThe objective of this study is to investigate the workload for radiologists during on-call hours and to quantify the 15-year trend in a large general hospital in Western Europe.MethodsData regarding the number of X-ray, ultrasound and computed tomography (CT) studies during on-call hours (weekdays between 6.00 p.m. and 7.00 a.m., weekends, and national holidays) between 2006 and 2020 were extracted from the picture archiving and communication system. All studies were converted into relative value units (RVUs) to estimate the on-call workload. The Mann–Kendall test was performed to assess the temporal trend.ResultsThe total RVUs during on-call hours showed a significant increase between 2006 and 2020 (Kendall's tau-b = 0.657, p = 0.001). The overall workload in terms of RVUs during on-call hours has quadrupled. The number of X-ray studies significantly decreased (Kendall's tau-b = − 0.433, p = 0.026), whereas the number of CT studies significantly increased (Kendall's tau-b = 0.875, p < 0.001) between 2006 and 2020. CT studies which increased by more than 500% between 2006 and 2020 are CT for head trauma, brain CTA, brain CTV, chest CT (for suspected pulmonary embolism), spinal CT, neck CT, pelvic CT, and CT for suspected aortic dissection. The number of ultrasound studies did not change significantly (Kendall's tau-b = 0.202, p = 0.298).ConclusionsThe workload for radiologists during on-call hours increased dramatically in the past 15 years. The growing amount of CT studies is responsible for this increase. Radiologist and technician workforce should be matched to this ongoing increasing trend to avoid potential burn-out and to maintain quality and safety of radiological care.

‘Hello, MaxFax on-call?’ – maxillofacial ‘bleep sheet’ proforma for on-call referrals

The on-call component of a dental core training (DCT) post in oral and maxillofacial surgery (OMFS) is considered to be the most daunting and challenging aspect of the job. The average trainee is a singly-qualified dentist with limited knowledge and experience of managing OMFS presentations. Given the short duration of DCT posts, there is a continual rotation of junior staff through OMFS departments with a varying skillset and knowledge mix. As such, the consistent recording of appropriate information remains a constant challenge. The coronavirus pandemic has presented a unique situation in which the majority of dental foundation trainees (DFTs) entering OMFS DCT posts will only have around six months experience of independent practice. This lack of experience and onerous on-call workload could be a potentially dangerous combination, especially during nightshift patterns of on-call. We demonstrate that implementation of an on-call bleep-sheet proforma provides a validated, standardised, systematic, and chronological method of record keeping that exceeds the minimum required standard of clinical governance, in an era where junior trainees entering OMFS will have had even more limited experience than normal.

Influence of patient and provider factors on the workload of on-call physicians: A general internal medicine cohort observational study.

Factors associated with the physician workload are scarcely reported. The study aims to investigate the associated factors of on-call physician workload based on a published conceptual framework.The study was conducted in a general internal medicine unit of National Taiwan University Hospital. On-call physician workloads were recorded on a shift basis from 1198 hospitalized patients between May 2010 and April 2011. The proxy of on-call workloads included night calls, bedside evaluation/management (E/M), and performing clinical procedures in a shift. Multivariable logistic and negative binomial regression models were used to determine the factors associated with the workloads of on-call physicians.During the study period, 378 (31.6%) of patients had night calls with related workloads. Multivariate analysis showed that the number of patients with unstable conditions in a shift (odds ratio [OR] 1.89 and 1.66, respectively) and the intensive care unit (ICU) training of the nurse leader (OR 2.87 and 3.08, respectively) resulted in higher likelihood of night calls to and bedside E/M visits by the on-call physician. However, ICU training of nurses (OR = 0.37, 95% confidence interval: 0.16–0.86) decreased the demand of performing clinical procedures by the on-call physician. Moreover, number of patients with unstable conditions (risk ratio [RR] 1.52 and 1.55, respectively) had significantly increased the number of night calls and bedside E/M by on-call physicians by around 50%. Nurses with N1 level (RR 2.16 and 2.71, respectively) were more likely to place night calls and facilitate bedside E/M by the on-call physician compared to nurses with N0 level. In addition, the nurse leaders with ICU training (RR 1.72 and 3.07, respectively) had significant increases in night calls and bedside E/M by the on-call physician compared to those without ICU training.On-call physician workload is associated with patient factors and the training of nurses. Number of unstable patients in a shift may be considered in predicting workload. The training of nurses may improve patient safety and decrease demand for clinical procedure.

Increasing Neuroradiology Exam Volumes On-Call Do Not Result in Increased Major Discrepancies in Primary Reads Performed by Residents

Background and Purpose: A common perception is that increased on-call workload leads to increased resident mistakes. To test this, we evaluated whether increased imaging volume has led to increased errors by residents.Materials and Methods: A retrospective review was made of all overnight neuroradiology CT exams with a primary resident read from 2006-2010. All studies were over-read by staff neuroradiologists next morning. As the volume is higher on Friday through Sunday nights, weekend studies were examined separately. Discrepancies were classified as either minor or major. “Major” discrepancy was defined as a discrepancy that the staff radiologist felt was significant enough to potentially affect patient care, necessitating a corrected report and phone contact with the ordering physician and documentation. The total number of major discrepancies was recorded by quarter. In addition, the total number of neuroradiology CT studies read overnight on-call was noted. Results: The mean number of cases per night during the weekday increased from 3.0 in 2006 to 5.2 in 2010 (p<0.001). During the weekend, the mean number of cases per night increased from 5.4 in 2006 to 7.6 in 2010 (p<0.001). Despite this increase, the major discrepancy rate decreased from 2.7% in 2006 to 2.3% in 2010 (p=0.34).Conclusion: Despite an increase in neuroradiology exam volumes, there continues to be a low major discrepancy rate for primary resident interpretations. While continued surveillance of on-call volumes is crucial to the educational environment, concern of increased major errors should not be used as sole justification to limit autonomy.

Radiology registrar on-call reporting accuracy

Radiology registrar on-call reporting accuracy

What drives the ‘August effect’? A observational study of the effect of junior doctor changeover on out of hours work

ObjectiveTo investigate whether measurements of junior doctor on-call workload and performance can clarify the mechanisms underlying the increase in morbidity and mortality seen after junior doctor changeover: the ‘August effect’.DesignQuantitative retrospective observational study of routinely collected data on junior doctor workload.SettingTwo large teaching hospitals in England.ParticipantsTask level data from a wireless out of hours system (n = 29,885 requests) used by medical staff, nurses, and allied health professionals.Main outcome measuresNumber and type of tasks requested by nurses, time to completion of tasks by junior doctors.ResultsThere was no overall change in the number of tasks requested by nurses out of hours around the August changeover (median requests per hour 15 before and 14 after, p = 0.46). However, the number of tasks classified as urgent was greater (p = 0.016) equating to five more urgent tasks per day. After changeover, doctors took less time to complete tasks overall due to a reduction in time taken for routine tasks (median 74 vs. 66 min; p = 3.9 × 10−9).ConclusionThis study suggests that the ‘August effect’ is not due to new junior doctors completing tasks more slowly or having a greater workload. Further studies are required to investigate the causes of the increased number of urgent tasks seen, but likely factors are errors, omissions, and poor prioritization. Thus, improved training and quality control has the potential to address this increased duration of unresolved patient risk. The study also highlights the potential of newer technologies to facilitate quantitative study of clinical activity.

Using telephone logs instead of databases to accurately estimate neurosurgical on-call workload

Background. Maintenance of on-call referrals databases is on the rise in neurosurgical units across the UK and helps provide data to estimate workload. We hypothesize that these databases underestimate the workload and propose the use of the number of telephone calls to the on-call registrar as an easily obtainable and valid measure of workload. Methods. Data were obtained from a referrals database maintained and completed by the neurosurgical registrars and the hospital switchboard telephone logs. Data were analysed using JMP 8.0.2 (SAS Institute, Cary, NC). Results. We found a large degree of disparity between the number of phone calls and the number of recorded referrals. The median number of phone calls to the on-call registrar per day was 78 (Interquartile range 59–106); but the median number of recorded referrals was 12 (Interquartile range 8–16). 49.8% of the calls were received out-of-hours (1700–0800 and weekends) and the maximum number of calls was received on a Friday. Data derived from both sources (database and switchboard logs) showed a close visual correlation. Conclusion. We argue that on-call logs are an easily obtainable, reliable and internally validated measure of activity. We recommend the use of such data in other centers to establish the nature of on-call activity and tailoring of the rotas to comply with current guidance to provide a mix of service and training.

Emergency neurosurgical referrals in the North East of England – trends over four years 2008–2011

Aims. On-call referrals are a considerable part of the neurosurgical workload. Many neurosurgical centres in the UK have now adopted the practice of maintenance of electronic databases to keep records of on-call activity. We analysed the neurosurgical on-call referrals database maintained at the Newcastle General Hospital (NGH)/Royal Victoria Infirmary (RVI) to assess any trends in the nature of referrals. Methods. Retrospective review and statistical analysis of a contemporaneously populated referrals database, maintained at the Regional Neurosciences Unit in Newcastle. Data were analysed from August 2008 to April 2011. A three point moving average was used to depict trend in the number of referrals. Descriptive statistics were used to display other trends. Analysis was conducted using JMP 8.0.2 (SAS Institute, Cary, NC, USA). Results. Our analysis reveals that the number of emergency referrals to neurosurgery in the North East of England is increasing year-on-year. Mean number of referrals per day has increased by almost 5 over the study period (9.06 in 2008 compared to 13.93 in 2011). The major diagnoses that account for this increase are lumbar degenerative conditions, intracerebral haematomas, spinal trauma and subarachnoid haemorrhage. 50% of the patients are referred out of hours and approximately one-third are admitted. In contrast, 47% of all referrals to rule out a cauda equina syndrome, need admission for scanning. General practitioners (GP) are the single biggest source of referral outside of the parent NHS trust and 47% of the GP referrals are regarding lumbar degenerative conditions and cauda equina syndrome. Conclusions. Continuously increasing referrals have implications on cost, staffing and sustainability of the service. Alternative referral pathways, especially for referrals from primary care, must be considered to restore the on-call workload to ‘true’ neurosurgical emergencies.

How do rural GPs’ workloads and work activities differ with community size compared with metropolitan practice?

Rural communities continue to experience shortages of doctors, placing increased work demands on the existing rural medical workforce. This paper investigates patterns of geographical variation in the workload and work activities of GPs by community size. Our data comes from wave 1 of the Medicine in Australia: Balancing Employment and Life longitudinal study, a national study of Australian doctors. Self-reported hours worked per usual week across eight workplace settings and on-call/ after-hours workload per usual week were analysed against seven community size categories. Our results showed that a GP's total hours worked per week consistently increases as community size decreases, ranging from 38.6 up to 45.6h in small communities, with most differences attributable to work activities of rural GPs in public hospitals. Higher on-call workload is also significantly associated with smaller rural communities, with the likelihood of GPs attending more than one callout per week ranging from 9% for metropolitan GPs up to 48-58% in small rural communities. Our study is the first to separate hours worked into different work activities whilst adjusting for community size and demographics, providing significantly greater insight to the increased hours worked, more diverse activities and significant after-hours demands experienced by current rural GPs.

On-call emergency workload of a general surgical team

Background:To examine the on-call emergency workload of a general surgical team at a tertiary care teaching hospital to guide planning and provision of better surgical services.Patients and Methods:During six months period from August to January 2007; all emergency calls attended by general surgical team of Surgical Unit II in Accident and Emergency department (A and E) and in other units of Civil, Hospital Karachi, Pakistan were prospectively recorded. Data recorded includes timing of call, diagnosis, operation performed and outcome apart from demography.Results:Total 456 patients (326 males and 130 females) were attended by on-call general surgery team during 30 emergency days. Most of the calls, 191 (41.9%) were received from 8 am to 5 pm. 224 (49.1%) calls were of abdominal pain, with acute appendicitis being the most common specific pathology in 41 (9.0%) patients. Total 73 (16.0%) calls were received for trauma. Total 131 (28.7%) patients were admitted in the surgical unit for urgent operation or observation while 212 (46.5%) patients were discharged from A and E. 92 (20.1%) patients were referred to other units with medical referral accounts for 45 (9.8%) patients. Total 104 (22.8%) emergency surgeries were done and the most common procedure performed was appendicectomy in 34 (32.7%) patients.Conclusion:Major workload of on-call surgical emergency team is dealing with the acute conditions of abdomen. However, significant proportion of patients are suffering from other conditions including trauma that require a holistic approach to care and a wide range of skills and experience. These results have important implications in future healthcare planning and for the better training of general surgical residents.

Association of Workload of On-Call Medical Interns With On-Call Sleep Duration, Shift Duration, and Participation in Educational Activities

Further restrictions in resident duty hours are being considered, and it is important to understand the association between workload, sleep loss, shift duration, and the educational time of on-call medical interns. To assess whether increased on-call intern workload, as measured by the number of new admissions on-call and the number of previously admitted patients remaining on the service, was associated with reductions in on-call sleep, increased total shift duration, and lower likelihood of participation in educational activities. Prospective cohort study of medical interns at a single US academic medical center from July 1, 2003, through June 24, 2005. Of the 81 interns, 56 participated (69%), for a total of 165 general medicine inpatient months resulting in 1100 call nights. On-call sleep duration, estimated by wrist watch actigraphy; total shift duration, measured from paging logs; and participation in educational activities (didactic lectures or bedside teaching), measured by experience sampling method via a personal digital assistant. Mean (SD) sleep duration on-call was 2.8 (1.5) hours and mean (SD) shift duration was 29.9 (1.7) hours. Interns reported spending 11% of their time in educational activities. Early in the academic year (July to October), each new on-call admission was associated with less sleep (-10.5 minutes [95% confidence interval {CI}, -16.8 to -4.2 minutes]; P < .001) and a longer shift duration (13.2 minutes [95% CI, 3.2-23.3 minutes]; P = .01). A higher number of previously admitted patients remaining on the service was associated with a lower odds of participation in educational activities (odds ratio, 0.82 [95% CI, 0.70-0.96]; P = .01]. Call nights during the week and early in the academic year were associated with the most sleep loss and longest shift durations. In this study population, increased on-call workload was associated with more sleep loss, longer shift duration, and a lower likelihood of participation in educational activities.