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AAGBI Linkman Conference 20 th Sept 2011 Dr Phil Das, Peterborough.

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Presentation on theme: "AAGBI Linkman Conference 20 th Sept 2011 Dr Phil Das, Peterborough."— Presentation transcript:

1 AAGBI Linkman Conference 20 th Sept 2011 Dr Phil Das, Peterborough

2  Background 2007 - 2010 ♦Reduction in non consultant grades ♦Ongoing discussion around rotas  2011 ♦Change to OOH Cover inevitable ♦Internal Opposition and Treachery ♦External Obstruction ♦Proposed Trial change  O&G resistance  The way forward Anaesthetic Emergency Cover 2011 2

3  Suspension of HSMP (Highly Skilled Migrant Programme) November 2006  Implementation of MMC August 2007  Implementation of EWTD - 48 hour max. Overall reduction in non consultant grades to run emergency rotas  Increased Staff Grades – but 6 of 13 resigned/poached Anaesthetic Emergency Cover 2011 3

4  Ongoing discussions ♦no trainee after midnight ♦resident consultant ♦Cost in lost sessions = 4-5 new consultants ♦Locums used each year August - October  Nov/Dec 2010 moved to single site hospital Anaesthetic Emergency Cover 2011 4

5 5 Peterborough Maternity Unit Peterborough District Hospital Edith Cavell Hospital

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8 Peterborough City Hospital fully open ♦Single site (at last) ♦Problems with equipment, operation & processes ♦Massive £38 million budget deficit ♦CEO long term sick leave ♦Job cuts – ‘severance scheme’ ♦August trainee shortage problem loomed ♦Warned ‘no money for locums’ Anaesthetic Emergency Cover 2011 8

9 April 13 th Department Business Meeting. ♦Clinical Tutor announcement From Monday 18 th July there will no theatre trainee after midnight May 12 th Special Department Meeting ♦Discussion of ‘no trainee after midnight’ plan Other hospitals cited in support (Exeter, Taunton) ♦Opposition from within Disliked change of hours/workload/responsibilities Wanted more written details and increased remuneration June 7 th Trust CGC Meeting ♦Presentation by RG – OOH incl. morbidity/mortality in other hospitals vs Peterborough ♦Agreed to set up ‘Steering Group’ to reduce OOH Surgery Anaesthetic Emergency Cover 2011 9

10 June 16 th Department Business meeting ♦Out of hours cover discussed: Why change was needed What changes were proposed Anaesthetic Emergency Cover 2011 10

11  Reduction in trainee numbers and hours worked  Eight novice trainees starting in August - 3 months to train  Unable to cover 3 rota tiers full time with staff available  Financial Constraints – high cost of locum cover  Consultant delivered service for sickest patients OOH deemed to be best practice...... Anaesthetic Emergency Cover 2011 11

12  No resident theatre trainee midnight to 7:30am  No change to ITU or Maternity trainee shifts (24hr cover)  Theatre cases after 10:30pm consultant decision only  More urgent emergencies (while consultant in transit) to be dealt with by ITU anaesthetist.  Assistance from Maternity trainee if not occupied on Labour Ward.  ITU consultant to come in and assist if appropriate...... Anaesthetic Emergency Cover 2011 12

13 June 16 th Department Business meeting (cont) ♦Proposed plans for no trainee after midnight ♦Consultant resident until midnight – on call after June 21 st email from obs. consultant anaesthetist (‘Agent X’) to key O&G personnel You may have heard through the grapevine that there are plans afoot to change the way the anaesthetic cover for nights is to be provided……......obstetric trainee will be holding the arrest bleep and will also be expected to attend to the sick patients before the anaesthetic consultant arrives..... June 22 nd multiple emails (responses escalated up)……. It is clear that there are significant potential risks.............. (Risk & Lit).........we would be severely criticised for having just one anaesthetist on site if anything went wrong (Medico-legal).......the plan described by ‘X’ in her email below must be revised as it will not meet these standards and will therefore be unacceptable on safety grounds. (O&G Governance Lead) Anaesthetic Emergency Cover 2011 13

14 June 30 th 20 out of 21 generalists voted to implement Trial change to evening & night cover for 3 months from August July 19th Guidelines and Scenario docs circulated before department meeting Guidelines and Scenario docs forwarded to O&G by ‘Agent X’ July 20 th email + 2 page letter from O&G. I understand that you have taken an anaesthetic trainee off the night rota and clearly there is now a gap in the service provision. There are clear safety standards documented around Anaesthetic provision on Labour Ward......... Anaesthetic Emergency Cover 2011 14

15 July 22 nd Department Business Meeting Documents for trial of OOH cover approved July 26th Trial supporting documents circulated widely July 27 th & 28 th Multiple email replies (escalated up to management)….. …concerned about the provision for cover for the Trauma Team. (Trauma Lead) …. formally express my concerns as the Matron …..who will take responsibility when the first patient dies?....I fear there is an increased likelihood of no one turning up to manage the airway Trial start postponed ♦To obtain more supporting evidence ♦Locums to fill gaps Anaesthetic Emergency Cover 2011 15

16 August 3 rd CGC Meeting. O&G presented Risk Assessment Document... Significant Hazards Non adherence to NHSLA maternity standards in relation to ‘safer childbirth’ RCOG 2007 …………………… Adverse Effects Unnecessary stress for staff. Maternal death Severe disability to baby Death of baby Adverse reputation to Trust Risk of litigation to Trust Reinforced decision to postpone trial Anaesthetic Emergency Cover 2011 16

17 Evidence gathering.......... September 6 th CGC meeting  O&G + ‘Agent X’ in opposition  Presentation addressing issues raised by O&G Out of Hours Emergency Cover 2011 17

18 Anaesthetic Emergency Cover 2011 18 Safety Issues and feasibility  At least 15 other hospitals run a system of cover with no theatre anaesthetic trainee 24:00 to 08:00  No increase in adverse incidents related to change Published Documents  ‘Breached guidelines’

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23 Staffing The duty anaesthetist should be immediately available for the obstetric unit 24 hours per day. No change Duties If the anaesthetist has other responsibilities, these should be of a nature that would allow the activity to be delayed or interrupted should obstetric analgesia or anaesthesia demands arise. The new scheme documents specify this. Responsibilities The duty anaesthetist for obstetrics should not, in addition, be responsible for the intensive care unit or other anaesthetic duties. No sole responsibility for other duties. Anaesthetic Emergency Cover 2011 23

24 Changes to appease O&G. A. General Principles ♦The maternity trainee may occasionally take on some more general responsibility between midnight and 08:00 but must be immediately available at all times to attend the labour ward. B. Scenario Guidelines 1.Cardiac arrest calls ♦c. If the ICU trainee is not immediately available...........should also arrange to fast bleep the maternity trainee (who may be able to respond if not occupied on the delivery unit). 2.Assistance in theatre for complex case such as polytrauma or ruptured AAA ♦ICU trainee -> Maternity trainee -> ICU consultant Anaesthetic Emergency Cover 2011 24

25 Risk Management Considerations  Difficulty obtaining locums at a time of increased demand  Variable quality of locums sent – unlikely to be as good as our own trainees  Locums unfamiliar with layout and procedures in hospital  Locums may turn up late or not at all  Consultant having to ‘act down’ if no locum – loss of routine sessions..... Anaesthetic Emergency Cover 2011 25

26 Financial Considerations  Locum Costs 2009 - approx £180,000 (£14,000 pw)  Locum Costs 2010 – approx £123,000 (£9,519 pw)  Locum Cost 2011 (interim) - approx £6,300 pw  Locum Cost during Trial £0 Anaesthetic Emergency Cover 2011 26

27 September 6 th CGC meeting.  Approval given to commence the Anaesthetics Emergency Cover Out of Hours Trial on Thursday 8th September 2011  Email announcement and supporting documents sent out Emails in response………. (whatif)…a 2nd urgent Obstetric case requires a theatre immediately (O&G Cons.) …. concerns … we do not have staff trained to anaesthetic standard covering every night(Trauma Lead) I hope this will not have an impact upon the Medical Registrar at night (Respiratory Physician) Unfortunately, taking out this one inexperienced trainee seems to have had a catastrophic effect on anesthetic cover......(Colorectal surgeon) Out of Hours Emergency Cover 2011 27

28 However……………………….. Despite all the grumbling…………. September 8 th Trial change in OOH cover started. So far so good. Anaesthetic Emergency Cover 2011 28

29  The trial continues  Ongoing work to reduce emergency OOH operating  Planned weekend Trauma lists  Careful detailed audit  Revert back to the original scheme from Mon 31 st October  Review trial data  Discussion/decisions ♦Full implementation ♦Partial implementation ♦Yearly 3 month implementation ♦Non implementation – employ locums 3 months each year Anaesthetic Emergency Cover 2011 29

30 Questions ? ? ? ?


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