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Bucks Urgent Care (BUC) Out of Hours Guide for GPRs August 2013. Dr. Michael Ip BUC Associate Medical Lead & Dedicated OOH GP. Out of Hours Services. Since the revised GP contract in 2004 OOH services are contracted by the PCT

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bucks urgent care buc out of hours guide for gprs august 2013

Bucks Urgent Care (BUC) Out of Hours Guide for GPRsAugust 2013

Dr. Michael Ip

BUC Associate Medical Lead

& Dedicated OOH GP

out of hours services
Out of Hours Services
  • Since the revised GP contract in 2004 OOH services are contracted by the PCT
  • Classically seen as NIGHT work, it covers evenings, nights, weekends and bank holidays (e.g. 66% of the week).
  • Examples of OOH Providers
  • MKdoc (Milton Keynes)
  • West Call (West Berkshire) & EBPC (East Berkshire)
  • Herts Urgent Care (HUC) Hertfordshire
  • Dalriada Urgent Care (DUC) Co. Antrim
  • Western Urgent Care (WUC) Londonderry
the origin of buc
The Origin of BUC
  • HARrow Medics Out of hours Network Inc (Harmoni)
  • Started in 1996, physically based out of Northwick Park Hospital
  • Originally a co-operative of 104 Harrow GPs, to cover their collective patients outside of normal surgery hours.
  • It replaced the previous Buck’s Co-ops: AYDOC & WYDOC in 2004 till 2009 as part of a national strategy.
  • Harmoni Bucks then joined with the 2 local GP collaborative: Chiltern Health (South Bucks) and Vale Health (North Bucks)
  • Forming Bucks Urgent Care (BUC) (Thankfully we are not located in Flintshire!)
  • BUC commissions Harmoni to provide the OOH service.
  • Harmoni was purchased by Care UK in November 2012.
  • Care UK also locally run the Cressex Diagnostics Centre and the MSK Service, along with HMPs and a nursing home (Catherine court).
how many patients do we cover bucks 2011 census
How Many Patients do we cover? (Bucks 2011 Census)
  • We now cover 505,000 people in 2011! (previously 479,000 in 2001)
  • 17% are over the age of 65.
how many patients do we cover
How Many Patients do we cover?
  • Resident institutions: Nursing & Residential (approx 150),
  • Community Hospitals (4)
  • Prisons (3)
  • RAF Bases
  • Every GP surgery (200)
  • Bucks Stats June 2013
  • 4956 (6799 in 2012) total contacts
  • Advice: 723 (15%)
  • PCC: 2478 (50%)
  • Visits: 657 (13%)
  • A&E/999: 203 (4%)
  • Other: (18%)
gp vts ooh training st3 start point
GP VTS OOH Training (ST3 Start point)
  • From August 2013
  • GPRs (ST1,2,3 in General Practice) have to complete set “Hours” not “Sessions”.
  • 6hours per month in General Practice.
  • E.g. 108 hours for 18months Training (36hours/6months as ST2, 72hours/12months as ST3).
  • Part Time GPRs/LTFT trainees need the same total OOH experience but worked pro rata during the training (rather than the calendar) year.
gp vts ooh training types of clinical sessions available as listed on rotamaster
GP VTS OOH Training – Types of Clinical Sessions available (as listed on Rotamaster)

Base/Triage (“Bu: Location Patient Clinic/Triage”)4-6 hours, primarily Base patients, but when not seeing patients then helping triage

Mobile/Base (“Bu: Location Home Assessment\Triage”)5-8hours, primarily visiting, but when not visiting then helping base or triage

GP Triage (“Bu: GP Speak to”)4-6 hours mainly triage, but if needed for other resources, may be asked to see base patients or do home visits. Can occur at any of our clinical locations and the Smeaton Close Call Centre in Aylesbury. Please note that this experience has been re-introduced following the introduction of NHS 111.

MIIU 6hours, available only as a one off RED Session for a handful of GPRs

Work Force Deployment

Weekday evenings:

2 Base GPs (2 Bases) 5 hours shift.

2 Visiting GPs (2 Cars) 4.5hours shift.

1 Triage GP 5 hours shift.

Weekends:

4+Base GPs (4 Bases) 4/5/6 hours shift.

4+Visiting GPs (4+ Cars) 5/6 hours shift.

2+Triage GPs 4/5/6/hours shift.

Page 10

gp vts ooh training clinical competency classification of progress
GP VTS OOH Training- Clinical Competency Classification of Progress

Registrar Sessions are clinically labelled as:

Red Sitting in with a BUC Supervisor/GP Trainer with some observed consultations/learning Adastra.

AmberInteracting with patients under direct/nearby observation of BUC Supervisor/GP Trainer.

GreenInteracting with patients independently, with a BUC supervisor/GP trainer being contactable for support.

Please note the BUC supervisor/GP Trainer is not to be confused with your own Personal GP trainer in surgery.

GPRs use the online booking process to book Red & Amber Sessions. Green Sessions have to be booked manually.

Page 11

slide12
GP VTS OOH Training- Guide to allocating your hours across the Clinical Sessions, Clinical Competencies, and ST2/ST3.

Red should be limited to 4-5 sessions (24hours) within ST2 period.

Approximately 7-9 Amber sessions (42-54hours across ST2 & ST3)

Approximately 6 Green sessions (36hours) at end of ST3 period.

Depending on your ability you may go from amber to green very quickly (see document).

Spread your sessions out across the 3 clinical session types e.g. PCC/Triage/Visits e.g. do not do 18 visiting sessions.

Page 12

gp vts ooh training shift tips
GP VTS OOH Training-Shift Tips
  • Depending on your ability you may go from amber to green very quickly (see document).
  • Some GPRs may need more Amber experience.
  • Spread your sessions out across the 3 clinical session types e.g. PCC/Triage/Visits e.g. do not do 18 visiting sessions.
  • The length of sessions vary, and you should ideally stay for the whole booked session.
  • On Occasion you may need to leave the session early either due to other commitments or for example if you are nearing the end of your 36hour limit within your RED or AMBER sessions; if this is the case, then our Rota Team must be notified of this at the time that you book the session and cannot be accommodated at the last minute. This also cannot be promised on visiting shifts and cannot be carried out on GREEN sessions.
  • Do not book a whole load of sessions and then cancel them.
  • Ensure you do at least one amber or green session during a bank holiday!
  • There should be a 20 minute protected time, debrief session at the end of every session with the BUC Supervisor/GP Trainer.
  • You must complete your OOH training & Paperwork to be able to complete your VTS.
  • The last 2 Green Sessions should at least be booked in 2 months before you complete VTS.
gp vts ooh training shift tips1
GP VTS OOH Training-Shift Tips
  • Bring your OOH Paperwork with you (Record and Evaluation Forms).
  • Ensure you have your Windows and Adastra Username and Passwords; ensure they work and note the Windows one Expires and needs renewal.
gp registrar ooh training what do you need
GP Registrar OOH Training: what do you need?
  • 3 sets of Usernames & Passwords created by the Harmoni Rota Team (via completed Rota From).
  • Online booking service (Rotamaster) Username & password –this is to book your shifts.
  • Harmoni Windows Username & Password.
  • Adastra Username & Password - without this you cannot see patients!
  • Given the gaps between sessions your Windows Password is likely to expire or you may forget them, so ensure you have enough time at the start of a shift to reactivate this and make sure you bring them along (we do not always have access to the internet so don’t rely on looking up your old emails)
equipment
Equipment
  • The GP clinics and the Cars are all fully equipped
  • If you wish to bring your own equipment you are welcome to
  • A stethoscope is always handy!
  • Please ensure you know how to use a nebuliser, AED, IM & S/C injections.
gp registrar ooh training end of shift paperwork
GP Registrar OOH Training: End of Shift Paperwork
  • At the end of each shift you must fill out a “Record of OOH Session” form.
  • This is done in a debrief session lasting approximately 20minutes.
  • Later on in Green Sessions this is done remotely via phone calls/fax/email.
  • Scan into your E-portfolio and highlight any learning needs or completed competencies.
  • It is useful to have your previous forms for review, as you may have several supervisors; You can review any outstanding learning needs from previous sessions.
  • Identify aims and goals for current session which could include a DOP (direct observation of procedural skills) e.g. catheter, IM injection, dealing with mental health; preparation for the CSA (Clinical Skills Assessment exam as part of MRCGP).
  • Supervisors can sign off your DOPs in your e-portfolio
  • Discuss this regularly with your Practice trainer.
evaluation sheet evaluating your supervisor
This ensures we are providing you with appropriate training.

If there is a Supervision Problem, you can anonymise your form, of alternatively email or speak to me directly.

Please complete one for every session completed

Evaluation Sheet (Evaluating your supervisor)
amber to green confirmation form
The trainer is signing off the GP Registrar’s clinical competency based on their experience in In Hours General Practice

e.g. the Registrar can work independently in clinics and on home visits; maintaining good clinical notes and prescribing habits; keep to 10 minute consultations and know when they need to seek assistance and support from their supervisors.

Should a GP registrar not be up to this standard then they should under go further additional amber shifts with agreement with the BUC Clinical Lead.

Amber to Green Confirmation Form
gp registrar st3 ooh training green sessions
GP Registrar (ST3) OOH Training: GREEN Sessions
  • Green sessions means you are working independently.
  • In PCCs you will be alongside your BUC Supervisor/GP Trainer
  • On visits you will be able to access your BUC Supervisor/GP trainer by phone only.
  • Green sessions are usually in high demand towards the end of your year, so get them out of the way sooner.
  • You are the main clinician and have patients booked into your clinic, arrive on time, and please do not cancel this session once booked.
  • These sessions are booked in manually via a phone call to the Rota Team.
  • You are responsible for getting your paperwork completed at the end of every session (especially GREEN sessions); this is harder to do as your supervisor will usually be at another site.
  • I would recommend that you contact your supervisor at the start and end of each green session for remote sessions.
  • If you do not get the paperwork signed off; you haven’t completed the session.
cogped rcgp competencies to be assessed july 2010
COGPED/RCGP Competencies to be assessed July 2010
  • The six generic competencies, embedded within the RCGP Curriculum Statement on ‘Care of acutely ill people’, are defined as the:

1. Ability to manage common medical, surgical and psychiatric emergencies in the out-of-hours setting.

2. Understanding of the organisational aspects of NHS out of hours care.

3. Ability to make appropriate referrals to hospitals and other professionals in the out-of-hours setting.

4. Demonstration of communication skills required for out-of-hours care.

5. Individual personal time and stress management.

6. Maintenance of personal security and awareness and management of the security risks to others

actual examples of competencies to be assessed
Actual Examples of competencies to be assessed
  • Referring a patient as a medical or surgical emergency or to the community services e.g. arranging Out of Hours district nursing. Problems when Medical Reg refuses, or Obstetric Reg demands proof of foetal heart beat.
  • Dealing with a death, contrasting an expected death with a sudden death and the personnel and services involved. E.g. dealing with a death that requires immediate burial for cultural or religious reasons.
  • Problems of terminal care managed by Out of Hours provider. E.g. managing symptomatic patient and relatives.
  • Psychiatric problem dealt with Out of Hours e.g. a risk assessment/ MHA section.
  • Commentary on a management/organisational issue e.g. arrangements for Out of Hours care for Christmas/ Bank holiday weekend, a local flu/meningitis outbreak.
  • Critical Event and complaints report (if relevant).
actual examples of competencies opportunities that occur in ooh
Actual Examples of competencies & opportunities that occur in OOH
  • Clinical Exposure:
  • Palliative Care & End of Life
  • Acute Medical Emergencies
  • Acute Mental Health
  • Care of the Elderly and Safeguarding Issues
  • Child Protection
  • Practical Exposure:
  • IM injections, Catheters, PR examination.
  • “Luxury of time” on home visits to carry out DOPs or COT
rcgp eportfolio
RCGP ePortfolio
  • http://eportfolio.rcgp.org.uk/forms
  • DOPs (Direct Observation of Procedural Skills)
  • COT (Consultation Observation Tool)
  • CBD (Case Based Discussion)
  • MSF (Multi Source Feedback)
harmoni connect statutory mandatory e training
Harmoni Connect & Statutory/Mandatory E-training
  • For all Harmoni GPs (including GPRs before they start green sessions)
  • All Modules must be completed and passed
  • Allow approximately 6hours of E Learning Time.
  • These are all on line, across 2 websites requiring 3 separate Log Ins:
  • Harmoni Connect under the Education and Training Areas (results of these go to the BUC team)- use your Windows Username & Password to Access.
  • BMJ Learning* (results of these go to the BMJ and then the Training Team).
  • * You must use the Harmoni Connect Link to eBMJ and not the usual eBMJ web address.
  • You will need to obtain your eBMJ Voucher Code: you must sign a consent form and return it to Danielle Day who will then email you with a login voucher code.
  • You will need to create a BMJ username and password or use your current one.
harmoni connect how to access connect
Harmoni Connect – How to access Connect
  • Once you have obtained your username and password, go to the Harmoni Connect website: https://connect.harmoni.co.uk
  • The other way to access Harmoni Connect is via Adastra. There is a link down the left column once you have logged into Adastra (to right).
e modules required to be completed by all gprs
E-Modules required to be completed by all GPRs
  • Find Enclosed the Stat & Mand booklet and GPR Guide- please note that due to the CARE UK transition, some of the contact details are incorrect and have not been updated yet.
children young persons urgent care board new local guidance fever
Children & Young Persons Urgent Care Board: New Local Guidance: Fever.

Double click Image to enlarge

children young persons urgent care board new local guidance bronchiolitis draft
Children & Young Persons Urgent Care Board: New Local Guidance: Bronchiolitis (draft).

Double click Image to enlarge

children young persons urgent care board new local guidance gastroenteritis draft
Children & Young Persons Urgent Care Board: New Local Guidance: Gastroenteritis (Draft).

Double click Image to enlarge

performance management
Performance Management
  • 1% Clinical Notes Audit
  • Medicines/Prescribing Audit & Pact Data
  • Voice Recordings Audit
  • Feedbacks, Concerns
  • Compliments & Complaints
  • Performance Management Tool- Dashboard
problems experienced by previous gprs
Problems Experienced by previous GPRs
  • Delays in Progressing
  • Forgetting to bring along username/passwords and not being able to see patients independently.
  • Accessing the e-Learning Modules and completing them all in time to be able to start Green Sessions
  • Trainers feeling under confident in signing off the Amber to Green Forms (please contact me and your VTS Programme director if this occurs)
  • Left their OOH sessions to the end, and found it difficult to complete all of them on time.
  • Clinical Problems
  • Lack of global knowledge, despite topics being discussed and taught with recommendations for further reading.
  • Incorrect Prescribing
  • Poor Time Management
  • Poor documentation.
  • Asking for guidance from a supervisor, but then doing something completely different and incorrectly documenting this.
  • Inability to keep to time e.g. on visits/PCCs spending longer than 30mins per patient due to problems with knowing when to refer etc. Failure to develop throughout the year leading to dismissal.
significant events incidents concerns examples
Significant Events, Incidents, Concerns Examples
  • Prescribing Incidents
  • Chlorphenamine Syrup prescribed as 4mg QDS for 4days for a 2.5yr old child.
  • It should be 1mg QDS and PRN.(Feb 10)
  • Note OTC Piriton Branded Syrup is not licensed for children under the age of 1 (but generic oral solution is)
  • Ciproxin 250mg tds (Oct 2009)
  • It Should be 250mg/500mg bd.
  • Doxycycline 100mg twice a day for 14days x 50 (Jan 10)
  • Ensure you alter the amount to be issued.
  • Prescribing over the phone for a cellulitis in a 9 year old (Apr 2010)
  • Harmoni Policy is not to prescribe over the phone
  • Prescribing the MAP over the phone with a pharmacist request (May 2010)
  • Some pharmacists have an PGD and can prescribe MAP; it may also be available for free if the pt is aged 15-17.
  • Harmoni policy is not to prescribe over the phone even if a pharmacist is requesting this.
  • Prescribing 50mg midazolam in a syringe driver and removing analgesic patches (Apr 2010)
  • Do not remove analgesic patches
  • Do not use the BNF for syringe driver doses in palliative care; it is incorrect
  • Use the Harmoni Palliative Care Protocol.
  • Midazolam dose is 5-10mg!
  • Zopiclone 3.75mg take 1 at night x 28 (Apr 10) &co-codamol tablets 30mg + 500mg tablet(s) take two four times a day x100 (Dec 10)
  • Do not prescribe more than 7 days of any Rx especially for medications that can be abused e.g.
  • DHC, Benzos etc.
  • Ordering Oxygen on HOOF but not completing the process. Pt did not receive their Oxygen in 4.hours
  • Follow the Harmoni HOOF Guide. You must complete the HOOF form, get pt’s signed consent and then phone and fax the request to Dolby Vivisol, following it up with a phone call.
1 medical notes audit
1% Medical Notes Audit
  • July2011 Call No.12825 Audit Summary:
  • No examination carried out on a 47yr old with a UTI and autoimmune encephalitis.
  • Learning Points:
  • A full and appropriate examination is required even if it just appears to be a simple “UTI”. E.g. and abdominal examination and basic observations.
  • We have had cases before where E. Coli Sepsis and an appendicitis have all been missed.
  • September 2011 Call No.62798 Audit Summary:
  • Did not use prescribing module - this must be done even for hand written prescriptions
  • Learning Points:
  • Any Medication prescribed must be documented in the Adastra prescribe module, even for handwritten prescriptions. If you are unsure of how to code this then please refer to the Adastra Guide on connect.
  • There is no way of finding out the regime of the antibiotic prescribed, so should any problems arise we will not have this information for reference.
vr audit
VR Audit
  • Mar 2011 Call No. 15448 Audit Summary:
  • Needs to check patient details
  • Learning Points:
  • Although this may seem trivial it is very important at the beginning of any consultation to confirm the identity of the patient or their representative. We have had incidents where patient details have been entered into the wrong medical notes and this therefore leads to 2 patients not receiving appropriate management.
complaint b3511 march 2012 second hand histories
Complaint B3511 March 2012: Second Hand Histories

21yr old girl with headache, vomiting, photophobia, prev brain surgery for epilepsy- call from pt’s mother.

999 called initially for pt

Paramedic in attendance called BUC back (with some prompting from pt’s mother) and spoke to BUC GPR.

GPR Triage notes:

“Last 24 hrs has a bad migraine.Pain over the forehead and temple, both sides of the head.

Temp.37.8 .Has photophobia and sickness.

sats 98,pr 86/min,BM -5.8,obs-normal.

Paramedic wondered whether she could have a home visit to discuss about pain relief for migraine and sickness.”

WHAT WOULD YOU DO?

Page 38

complaint b3511 march 2012 second hand histories1
Complaint B3511 March 2012: Second Hand Histories

GPR outcome

“Diagnosis:headache?migraine

Treatment:Adv paramedic that Mum can buy OTC meds with anti sickness (paramax,migraine relieve etc).can try these

tablets.Reassured migraine will get better.call back if not better or if symptoms change”

Patient outcome:

Mom then asked for ambulance to take pt to hospital

Diagnosed with viral meningitis after an LP.

Learning Issues:

Speak to the pt or mother and get a first hand history

Be objective with presented findings

Follow the clinical clues

Complete the Harmoni Connect Meningitis Module

Page 39

coroner s case feb 2011
Coroner’s Case Feb 2011
  • Home Visit on a 40yr old alcoholic man with confusion & Vomiting.
  • NHSD Notes: Incoherent/disorientated/falling around/groaning for ongoing situation. Ambulance out on Thursday. And alcohol dependent and mental health issues. Not having any alcohol for several days. Mum with him at the moment. Please consider a home visit as unable to get out.
  • TAS Triage:Vomiting for the last week and own GP has prescribed buccastem.not able to have a conversation. Blotchy rash which comes and goes and does not blanch. Not hot but feels hot and puts himself in a cold bath. No headache, no photophobia. Not eating for the last week. now very weak. only taking water and his medication.
  • Past Medical History:Collapsed lungx3, mental health history. Alcohol dependent not taken any for 1 week. Never been sectioned or admitted to hospital
  • Medications:Dolmatil400mg bd (sulpiride), baclofen, lansoprazole, serenace (haloperidol).
  • parents are carers.
  • Plan:Urgent Home visit ?psychotic disorder with underlying physical problems. If worse parents to phone 999.
coroner s case feb 20111
Coroner’s Case Feb 2011
  • History: Ongoing mental problems, under the care of the mental health team and his regular GP care. 2 weekly periods of excessive vomiting and ?confusion with refusal of medication. This episode building over last 5-7days. Today refused medication and fluids. Most of the history obtained from mother. Normally has haloperidol 500mcg for acute episodes, but unable to take one this morning due to vomiting.
  • Examination:PERLA, responsive to questions and commands. Naked in cold bedroom, cooperative, slow movements. Mumbling speech.
  • Diagnosis:Exacerbation of psychotic condition.
  • Treatment: Haloperidol 2.5mg IM (with patient's consent) Advised mother to give medication again in 30min. Called back if worried.
coroner s case feb 20112
Coroner’s Case Feb 2011
  • Pt Died 6hrs later.
  • Cause of Death was “Alcoholic Ketoacidosis and Sulpiride Toxicity”
coroner s case feb 20113
Coroner’s Case Feb 2011
  • Medical History omits presence of GP Supervisor
  • Finer details of symptoms are absent, e.g. quantify the level of vomiting (is he dehydrated), given the alcohol history, need to ensure no blood (risk of varices).
  • Clues from triage not addressed e.g. rash, feeling hot and other symptomatic questions - diarrhoea, abdominal pain (to rule out pancreatitis, infection), no alcohol for 1week (could this have been delirium?)
  • Examination details are brief. Confusion could be quantified with Mini Mental State Basic observations not recorded and could possibly highlight underlying medical issue e.g. fever.
  • Location of Injection not stated. (The GPR confirms in her formal report that it was the right gluteal area).
  • Injection not coded in the prescribing module.
  • Overall History and examination have not sufficiently ruled out an organic cause e.g. metabolic problem, neurological event etc.
  • Inaction (inability to rule out other causes) may not have been in patient's best interest.
opportunities within buc
Opportunities within BUC
  • Opportunity for new GPs, and established GPs
  • Portfolio Career
  • Opportunity to learn new skills – fine tune your acute medicine
  • Work closely with a variety of people (Hospital/non-medical)
  • Clinical Supervisor role
  • Salary comparative to a partnered GP
  • Provision of training
  • Monthly teaching sessions, case discussion, audit, appraisal.
induction paperwork
Induction Paperwork
  • For Induction Session: Please complete all these now.
  • Sign In Sheet
  • Honorary Contract
  • Rota Form
  • Evaluation Form
  • For OOH Sessions: (Further Copies are also downloadable from Connect)
  • OOH Worksheet
  • Evaluation Sheet
  • Amber to Green Form
contact details
Contact Details
  • BUC Offices
  • 01296 850 007/ Fax 01296 393 906
  • For enquiries and updating us if you are having difficulty finding/getting to a session.
  • Rota Team
  • Emma.bowden@harmoni.co.uk (GPR Rota Organiser)
  • debbie.parkes@harmoni.co.uk
  • richard.bowden@harmoni.co.uk
  • bev.brown@harmoni.co.uk
  • Kate.merridan@harmoni.co.uk
  • Clinical Lead
  • Michael.ip@bucksurgentcare.co.uk