Appropriate Medical Staffing Improves Patient Safety, Training and Doctor Wellbeing.

Background Cross-covering of medical and surgical specialities out-of-hours is a problem in many hospitals, leaving trainee doctors responsible out-of-hours for patients they have never met, in specialities where they do not normally work. This has implications for patient safety and doctor wellbeing. In our Trust, a historical decision resulted in trainee doctors in Trauma & Orthopaedics and Ear Nose and Throat Surgery being reallocated out-of-hours to cross-cover medical inpatients. This left one doctor cross-covering all surgical specialities, including General Surgery, Urology, Vascular, Ear, Nose and Throat surgery (ENT), Trauma & Orthopaedics (T&O) and Spinal Surgery. As the out-of-hours workload increased over time, this impacted negatively on patient safety and doctor wellbeing to a point where it became unsustainable. Methods Evidence of safety concerns relating to surgical night shifts was gathered from Exception Reporting data and anecdotally from the Postgraduate Doctor Forum. Once the scale of this problem was accepted by the hospital board, following the successful presentation of two Business Cases, 17 additional doctors were recruited. This recruitment reduced the cross-covering of specialities out-of-hours and enable adequate staffing throughout all departments. Qualitative evidence was gathered by surveying affected doctors before and after the change in order to assess its impact on doctor wellbeing, training and perceived patient safety. Quantitative analysis of Exception Reports and Immediate Safety Concerns was also performed. Results The survey results following the change were overwhelmingly positive, demonstrating a significant improvement in workload, rest breaks and quality of care for patients. Foundation doctors reported higher levels of confidence and enhanced training due to more consistent supervision. Job satisfaction improved, with 81% of surgical senior house officers reporting they would recommend their job, compared with 42% previously. Trends in out-of-hours Exception Reporting and patient safety concerns were analysed to show a moderate improvement following the intervention. Conclusion With the ever-increasing volume and complexity of patients presenting to global healthcare systems, it is key that staffing levels are safe and adequate in order to maintain patient safety and doctor wellbeing. This project has demonstrated how historic short-term fixes such as redeploying trainee doctors out of their home speciality and implementing cross-cover of multiple specialities can have detrimental long-term effects. Our preliminary data revealed multiple issues related to patient safety, junior doctor workload and lack of training opportunities. By using this data, and enlisting the help of multiple valued senior stakeholders, an acceptable Business Plan was approved by the Trust with a view to reversing these issues. The recruitment of additional Trust Grade doctors to create a third tier of the surgical out-of-hours cover has been instrumental in improving conditions within our Trust and has shown that adequate workforce planning is achievable when supported by robust evidence. This project could be used as a guide for other units seeking to make similar improvements.

Risk factors for endemic Acinetobacter Baumannii colonization: A case-case study.

BACKGROUND: Acinetobacter baumannii causes increasingly resistant nosocomial infections worldwide. Although some patients are already colonized with A baumannii on hospital admission, others become colonized with endemic strains that are more likely to be antibiotic-resistant. Colonization increases risk of infection and transmission to others. This study aimed to identify risk factors for colonization with endemic compared to sporadic A baumannii among hospitalized patients. METHODS: The study population were patients colonized with A baumannii at a single medical center during a 17-month period of active surveillance. Endemic A baumannii (cases) had a repetitive extragenic palindromic (REP) type that occurred 10 or more times during the surveillance period. Cases carrying 1 of the 5 endemic REP types were matched to comparison cases (controls) carrying sporadic strains by facility and time. RESULTS: There were 69 cases with REP-1, and 64 with REP-2-5. After adjustment, each unit increase in Schmid score was associated with a 70% increase in REP-1 carriage (P = .04) and a 50% increase in REP-2-5 (P = .07). Days in the intensive care unit prior to colonization, longer length of stay, immunosuppression, and the Charlson comorbidity index were not significantly associated with carriage of endemic strains. CONCLUSIONS: Following best practices for antibiotic stewardship and hygiene will help minimize the emergence and persistence of A baumannii strains adapted to the health care environment.

Reduction in late diagnosis of colorectal cancer following introduction of a specialist colorectal surgery service.

INTRODUCTION: An audit of patients presenting with colorectal cancer to our district general hospital during a 2-year period from November 1994 found that 12.1% of cases were diagnosed later than 6 months after initial presentation to a physician. This audit was repeated for a 2-year period from December 2001, to determine whether the introduction of a specialist coloproctology surgery service had led to a reduction in late diagnosis of colorectal cancer. PATIENTS AND METHODS: Case notes were reviewed of all patients presenting with colorectal cancer between December 2001 and November 2003. Late diagnosis was defined as diagnosis of colorectal cancer more than 6 months after their first attendance to either their general practitioner or district general hospital. The results were compared with those of the previous study. RESULTS: Of a total of 218 patients presenting with colorectal cancer during the study period, 14 (6.4%; 10 men and 4 women) satisfied the criteria for late diagnosis, with the longest delay being 12.5 months. Reasons for late diagnosis were false-negative reporting of barium studies (n = 3), inaccurate tumour biopsy (n = 2), concurrent pathology causing anaemia (n = 4), inappropriate delay in definitive investigation (n = 3), and refusal of investigation by patients (n = 2). CONCLUSIONS: There has been a reduction of nearly 50% (12.1% to 6.4%) in the proportion of patients with a late diagnosis of colorectal cancer compared with our previous audit. It is suggested that an important factor in this improvement in diagnosis has been the introduction of a specialist coloproctology surgery service.