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Out of Hours Cover The Peterborough Experience. AAGBI Linkman Conference 20 th Sept 2011 Dr Phil Das, Peterborough. Introduction. Background 2007 - 2010 Reduction in non consultant grades Ongoing discussion around rotas 2011 Change to OOH Cover inevitable

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Out of hours cover the peterborough experience

Out of Hours CoverThe Peterborough Experience

AAGBI Linkman Conference

20th Sept 2011

Dr Phil Das, Peterborough



  • 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

Pre 2008

Pre 2008

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

2008 2010

2008 - 2010

  • 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

Peterborough hospitals pre 2010

Peterborough Hospitals pre 2010

Peterborough Maternity Unit

Edith Cavell Hospital

Peterborough District Hospital

Anaesthetic Emergency Cover 2011

Peterborough city hospital 2010

Peterborough City Hospital 2010

Anaesthetic Emergency Cover 2011

Peterborough city hospital

Peterborough City Hospital

Anaesthetic Emergency Cover 2011

2011 peterborough city hospital

2011- Peterborough City Hospital

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

2011 train of events

2011- Train of events...


April 13th Department Business Meeting.

  • Clinical Tutor announcement

    From Monday 18th July there will no theatre trainee after midnight

    May 12thSpecial 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 7thTrust CGC Meeting

  • Presentation by RG – OOH incl. morbidity/mortality in other hospitals vsPeterborough

  • Agreed to set up ‘Steering Group’ to reduce OOH Surgery

  • Anaesthetic Emergency Cover 2011

    2011 discussions

    2011- Discussions

    June 16thDepartment Business meeting

    • Out of hours cover discussed:

      • Why change was needed

      • What changes were proposed

    Anaesthetic Emergency Cover 2011

    Why change

    Why Change?

    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 forsickest patients OOHdeemed to be best practice.


    Anaesthetic Emergency Cover 2011

    What change

    What Change?

    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

    2011 proposed change and treachery

    2011-Proposed change and treachery

    June 16thDepartment Business meeting (cont)

    • Proposed plans for no trainee after midnight

    • Consultant resident until midnight – on call after

      June 21st

      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 22nd

      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

    2011 t rial to go ahead but

    2011- Trial to go ahead but ...

    June 30th

    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 20th

    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

    2011 trial postponed

    2011-Trial postponed

    July 22nd Department Business Meeting

    Documents for trial of OOH cover approved

    July 26th

    Trial supporting documents circulated widely

    July 27th & 28th

    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

    2011 o g obstruction

    2011-O&G obstruction

    August 3rdCGC Meeting.

    O&G presented Risk Assessment Document ...

    Significant HazardsNon 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

    2011 crucial cgc meeting

    2011-crucial CGC meeting

    Evidence gathering ..........

    September 6thCGC meeting

    O&G + ‘Agent X’ in opposition

    Presentation addressing issues raised by O&G

    Out of Hours Emergency Cover 2011

    Addressing the o g concerns

    Addressing The O&G Concerns

    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’


    Anaesthetic Emergency Cover 2011

    Clinical negligence scheme for trusts maternity

    Clinical Negligence Scheme For Trusts - Maternity

    Anaesthetic Emergency Cover 2011

    Safer childbirth minimum standards rcog 2007

    Safer Childbirth – Minimum Standards...RCOG 2007

    Anaesthetic Emergency Cover 2011

    High quality women s healthcare rcog 2011

    High Quality Women’s Healthcare. RCOG 2011

    Anaesthetic Emergency Cover 2011

    Guidelines for obstetric anaesthetic services oaa aagbi 2005

    Guidelines For Obstetric Anaesthetic Services. OAA/AAGBI 2005

    Anaesthetic Emergency Cover 2011

    Common themes

    Common Themes


    The duty anaesthetist should be immediately available for the obstetric unit 24 hours per day.

    No change


    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.


    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

    Guidelines for provision of anaesthesia critical care services between 18 00 and 08 00

    Guidelines for provision of anaesthesia & critical care services between 18:00 and 08:00

    Changes to appease O&G.

    A. General Principles

    • The maternity trainee may occasionallytake 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 maybe 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

    Consequences of no change

    Consequences of No Change

    Risk Management Considerations

    Difficulty obtaining locums at a time of increased demand

    Variable quality of locums sent – unlikely to be as good as our owntrainees

    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

    Consequences of no change 2

    Consequences of No Change 2

    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

    2011 cgc meeting decision

    2011-CGC meeting decision

    September 6thCGC 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

    September 2011 trial up and running

    September 2011- Trial up and running


    Despite all the grumbling………….

    September 8th

    Trial change in OOH cover started.

    So far so good.

    Anaesthetic Emergency Cover 2011

    The way forward

    The Way Forward

    • 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 31st October

    • Review trial data

    • Discussion/decisions

      • Full implementation

      • Partial implementation

      • Yearly 3 monthimplementation

      • Non implementation – employ locums 3 months each year

    Anaesthetic Emergency Cover 2011

    Thank you

    Thank you






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