For the last few years all the hospitals in the UK have been changing junior doctors' rotas to become compliant with the. European Working Time Directive.
Bulletin October2006.qxp
25/09/2006
14:56
Page 318
DOI: 10.1308/147363506X148183
THE EWTD: FRIEND OR FOE TO QUALITY PATIENT CARE?
MBS Brewster, R Potter, D Power, V Rajaratnam and PB Pynsent Royal Orthopaedic Hospital, Birmingham
For the last few years all the hospitals in the UK have been changing junior doctors’ rotas to become compliant with the European Working Time Directive (EWTD). The first stage, requiring a junior doctor to work a maximum of 58 hours per week averaged over a 6-month period, became law in August 2004. In addition to new posts for junior doctors there have been schemes to facilitate the transition, such as the Hospital at Night programme. This was designed to use the minimum safe number of doctors from appropriate specialties with supporting medical staff to cover the hospital out of hours. It was required to make the most efficient use of this team and allow the junior doctor rotas to be compliant with the appointment of as few new posts as possible. Ann R Coll Surg Engl (Suppl) 2006; 88:318–319
Concern was raised by the nursing staff at a tertiary referral orthopaedic hospital that, since commencement of the new full shift rota, case notes appeared to contain less frequent documentation of clinical information. An audit was undertaken to evaluate these anecdotal reports.
After accounting for the maximum annual leave, bank holidays and night shifts, the percentage of time SHOs/junior orthopaedic surgeons were away from their normal duties (ie the time that requires cross-cover) was calculated from monthly rotas.
The aim of this project was to investigate whether new EWTD rotas had a significant effect on the frequency of clinical record keeping. In addition, the pre- and post-EWTD rotas were reviewed to assess the amount of crosscover required on each. Finally, the quality of the clinical entries was assessed.
During a one-week period the case notes of all the inpatients discharged were prospectively reviewed. ‘Gold standards’ for note keeping were created using direction from existing guidelines.1,2,3 The criteria to be met were as follows:
Methods The methods can be separated into two discrete sections: first, a comparison of the six months of rotas before August 2004 and the six months after August 2004; second, an assessment of the clinical notes taken during one week in October 2004. This week was chosen to be representative of the majority and, being undertaken roughly 10 weeks into the post, it was assumed that the junior doctors were clear about their duties and responsibilities. The rotas immediately pre- and postAugust 2004 were examined. Both were banded on a 2B pay scale reflecting weekly and unsociable hours worked. The post-August 2004 rota increased the number of SHO posts from nine on an oncall rota to eleven on a full shift rota. There were no alterations in inpatient numbers over this period and the structure of consultant-based SHO/junior orthopaedic surgeon posts remained the same.
318
> All patients required daily entries in clinical notes, except at weekends (unless this was the day of admission). Operation notes were counted as an entry. > Entries should be dated and signatures legible. > A consultant-led ward round should be documented for each admission lasting seven or more days (weekly for longstay patients). The results were calculated to discover the impact on the frequency of clinical records as a consequence of the need to cross-cover patients following implementation of the EWTD.
Results Junior doctors working the pre-EWTD rota were away from normal duties and therefore being covered by another team for 9.9% of the time (12.5 out of 126 days). Those working after implementation of the EWTD, with the addition of night duties were away from normal duties 23.0% of the time (29 out of 126 days).
Bulletin October2006.qxp
25/09/2006
14:56
Page 319
THE ROYAL COLLEGE OF SURGEONS OF ENGLAND B U L L E T I N
TABLE 1 NUMBER OF NOTE ENTRY OMISSIONS AND TEAM CARING FOR PATIENTS Patient days
Entries missed
Omissions
Named team present
500
113
22.6%
Cross-covering team
222
72
32.4%
During the week studied (in October 2004) there were 145 discharges, of which 139 (96%) notes were reviewed. The six case notes not reviewed had been transferred to another hospital with the patient. A total of 722 inpatient days were reviewed. These excluded weekends unless an admission had occurred (21 cases). The average length of stay was 6.7 days. A quarter (25.6%) of days had no entry in the notes and 27.3% of patients had no note documentation on the day of discharge. The percentage was calculated of missed entries occurring when the named team was present and when they were being cross-covered. Almost two-thirds (61%) of the missed entries occurred while the named team was present and almost twofifths (39%) of the entries missed occurred while the team was being crosscovered. These results could be misleading if not interpreted correctly and it should be remembered that the named team is
being missed if it occurred during the presence of the named team and, separately, during cross-covering of the patient. Following the rota for the study week, a total of 222 cross-covered and 500 named team patient days were recorded (Table 1). There was a 50% increase in missed entries while the teams were being cross-covered. To complete assessment of the entries under our criteria, it was noted that 17.2% of signatures were illegible and one entry had no signature at all. Three entries had no dates and 41.3% of those in hospital for seven or more days had no consultant-led ward round documented in the notes. In all, 64 (46%) notes were incomplete in some way using our ‘gold standards’.
Conclusion Due to the change in shift patterns experienced in the hospital, junior doctors are now away from what was considered their normal duties for a higher proportion of the time (23.0% vs
WHILE A TEAM IS BEING CROSSCOVERED, THE DOCUMENTATION IN PATIENTS’ NOTES IS MARKEDLY DECREASED.
related to reviews of patients (and therefore patient care), this translates to a reduction in patient care due to increased cross-covering under the new EWTD. Due to the financial and logistical implications of the EWTD, many of the compliant rotas nationwide have only come into practice since August 2004 and therefore will need time to iron out problems. As there are further planned reductions in working hours, solutions need to be found quickly. Some of the problems faced, such as legibility and date recording, can be addressed easily with repeated education, audit and self-inking rubber stamps. These are personalised with a doctor’s name and General Medical Council number. The bigger problems of patient care and compliance with the EWTD are complex and much more difficult to resolve. The increasing number of junior doctor appointments will undoubtedly help but it is the structure of the working programmes that needs to be addressed to allow best use of increasingly limited working time. Solutions may lie in creating a more ward-led rather than consultantled approach or appointing non-training doctors/assistants to reduce the less demanding, time consuming tasks. Our concern is that without dramatic changes in the structure and content of a junior doctor’s day, patient care will increasingly suffer as full implementation of the EWTD moves towards completion. References 1 Faculty of General Dental Practice. Clinical Examination and Record-keeping: Good Practice Guidelines. London: FGDP(UK); 2001. 2 Mann R, Williams J. Standards in medical record
present 77% of the time. Therefore, these results cannot be directly compared. In order to make them comparable, the likelihood was calculated of an entry
9.9%). It can be seen that while a team is being cross-covered, the documentation in patients’ notes is markedly decreased. If we assume clinical record entries are
keeping. Clin Med 2003; 3: 329–332. 3 Crawford JR, Beresford TP, Lafferty KL. The CRABEL score – a method for auditing medical records. Ann R Coll Surg Engl 2001; 83: 65–68.
319
