The importance of leaving on time whilst working in the NHS
Leaving on time is always a problem for health care professionals - more so for doctors. I have been working in the NHS for 5 years now ( 18 months as a non trainee SHO, 2 years as a core medical trainee and almost 2 years as a trainee registrar) and I always try to leave on time. I would like to share my tips with all of you to ensure you can do the same.
WHY THIS IS SO IMPORTANT FOR ME
I am married. We have a 3 year old daughter. Every minute spent at work is a minute less spent with her and my wife. Hence I am very particular about leaving on time. I came to this country from my home country for this very reason ( in my home country, I would be working in a government hospital from 0800 to 1500, coming home, sleeping for an hour or 2 to go back to a private clinic/hospital and work till midnight). I want to ensure I have a good quality of life to enjoy my career and job I will spend 50 to 60% of my time at. I want to ensure I am able to play with my daughter, read her a bedtime story and be there for her and my wife.
ROTA AS A SHO
SHO ON THE WARD
I always ensured that there was enough staffing on the ward. I would always check the rota on a Thursday and check how many SHOs, FY1s, ACPs and physician associates were on.
If there were less than the minimum requirement, I used to escalate early to the rota team.
Luckily, I had very good rota teams who already sorted it out beforehand ( Slough, Harrogate, York).
Despite that, I did this on a regular basis to ensure we were well staffed.
LAST MINUTE SICKNESS
Like every organization, we did have last minute sicknesses. If it was very busy, I would talk to the rota team and request them to arrange cover for the ward by seeing if other wards were overstaffed ( ie cross covering). I used to cross cover regularly as a non trainee and as a core medical trainee as I:
1. Got to see new cases
2. I knew that someone will take the same initiative when I am stuck in an understaffed ward.
However, if I had a clinic booked, I would let the rota team know that it is essential for my training and if they still wanted me to go, they would have to talk to my supervisor ( who always supported me- it happened only once or twice as I used to book clinics in advance ONLY when we had loads of doctors on the ward)
ON CALL
Luckily, the trusts I worked at as a SHO ( Wexham Park, Slough as a non trainee, Harrogate as a CMT 1, York as a CMT 2 trainee) and very pro-active rota teams.
They had an on call rota which was available to view for the whole year to all doctors and this way, they were able to identify locum gaps and us juniors were able to take them up as locums/ do swaps.
We did have last minute sickness on calls as well - however the management helped here by offering escalated rates.
WHAT HELPS:
1. Having an on call rota and ward cover rota visible to everyone. At my previous trust, we had a rota which showed gaps, how many doctors were on each medical ward. The rota team was able to send juniors home (if the ward was over staffed) to come in out of hours for locum pay ( sometimes enhanced rates)
2. Having a pro-active rota team
3. A few doctors being part of the rota team to help co-ordinate. In my previous trust, a gastro registrar was part of the rota team and she was very proactive.
4. Having an active WhatsApp group - most trusts have this on which understaffing is identified and colleagues help each other.
TRUSTS WHERE I HAVE SEEN THIS WORK:
1.York District Hospital
2. Scarboorugh District Hospital
WORKING ON THE WARD AS A SHO/REG
I worked in cardiology, general medicine/rheumatology and care of elderly as a non trainee. I then worked in respiratory, care of elderly, stroke, renal, gastro and neurology as a trainee SHO ( core medical trainee).
When I started working here, I used to work hard. I sometimes stayed late as I did not understand what was important. Soon, I realized how to prioritze jobs and ask for help early.
These was my 'ideal' work day:
0900 to 0930 HUDDLE
Attended by the discharge coordinator, consultant, registrar, junior doctors, ACPs, PAs, physiotherapist and OT.This is led by the nurse in charge. It is a quick summary of patients on the ward:
Mr A is a 80 year old gentleman, lives alone, admitted with CCF. On day 3 of IV furosemide and he is now off oxygen. There are no concerns from the overnight staff and I feel he can come off the IV furosemide. Can the therapy team kindly see him as he is approaching medically fit. If the medical team agrees that he can be started on oral diuretics and he is assessed by the therapists, he can potentially go home in the afternoon
Mrs X is a 90 year lady who is approaching end of life. Her EWS is 15 and she looks really unwell. She was seen just an hour ago by the on call team , a CXR, bloods were done and she was started on IV antibiotics. Currently she is not distressed but is on 15 liters of oxygen. She has a DNACPR form in her notes and is for ward based care. Can someone assess her first please? I feel we need to stop active treatment. The family has already been called and they are aware of her situation.
Mr G is a 85 year old, he was admitted with urosepsis. He is on day 5 of IV antibiotics and is feeling much better. Can we kindly review his IV antibiotics and switch them to oral antibiotics? He is completely independent on the ward and there are no therapy needs here. He can potentially go home
ADVANTAGES OF SUCH A HUDDLE:
1. Unwell patients are identified
2. Potential discharges are identified
3. The discharge coordinator can then feedback to the bed management how many beds will be available thus improve patient flow
4. The discharge coordinator can transfer these patients to the discharge lounge once they have been reviewed by the registrar/consultant thus freeing up beds early
5. The whole team knows what to do.
6. Any patients who are frail and need an escalation plan are identified
TRUSTS I HAVE SEEN THIS WORK REALLY WELL:
1. Scarborough hospital and York Hospital- some wards
2. Hull - AMU and some other wards
DISTRIBUTION OF DOCTORS
This can be done before the huddle or immediately after the huddle.
The junior doctors can be divided into a few groups :
- One can do the discharge summaries
- One can do the jobs from the consultant ward round
- One can do the jobs from the senior review of the unwell patient
- One doctor can be allocated to each consultant/ each bay
- One can do any procedures awaiting sign off ( like an ascetic drain/LP/chest drain,etc)
- If there are any additional doctors, they can attend clinics/ work on their QIPs
The ward clerk can then mention the contact details of the aforementioned dcotors on the white board so there is no confusion on who is resonsible for which patients
ADVANTAGES OF SUCH A SYSTEM:
1. Everyone knows who is responsible for which patients
2. Extra people are identified early and they can be allowed to spend that day with QIPs/clinics/ procedures hence meet their training needs.
TRUSTS I HAVE SEEN THIS WORK REALLY WELL:
Scarborough Hospital - Beech ward ( pre-covid)
WARD ROUNDS 0930 to 1200
The ideal ward round is led by a consultant / registrar.The consultant has 2 juniors
Doctor A prepares bed 1s notes, goes with the consultant to see bed 1 and scribes. During that time, Doctor B prepares bed 2s notes and doctor A continues with the next patient. They make a list of jobs and stop for urgent jobs.
I as a registrar prefer to work alone when there is not enough staff. If there is enough staff, I am happy for a SHO/FY1/ACP/PA to come join me and I do a bit of teaching. I try to do the following:
1. Teach them
2. Let them lead one consultation
3. Ask if they have any outstanding signs off on their portfolios and try to identify cases on whom I can sign them off.
If I am all alone, I as a registrar:
1. Do my own discharge summaries
2. I do my own bloods/cannulas
3. I DO NOT give silly jobs to my colleagues who might already be overwhelmed.
LUNCH 1200 to 1230
Ideally, the ward round should be completed by 1200 PM or whenever lunch is served to patients.During this time,
1. As lunch is being served to patients, you cannot see them ( Food is important - interrupting them during their meal is not a good idea unless there is an urgent concern to be sorted out).
2. The medical team should have their lunch - you cannot see any patient, you have done the urgent jobs during the ward so have lunch
AN UNWELL PATIENT DURING LUNCH
The senior most person should ideally stay. As a registrar , I stay on the ward ( I sneak out for a lunch at 1150 AM and come back in 10 minutes - yes, I eat really fast). I am fed and watered and I can:
1. Manage an unwell patient on my own
2. Do any urgent outstanding jobs from the ward round
3. Ensure all my colleagues go for lunch
1230 TO 1300
AFTERNOON HUDDLE
This huddle is attended by the discharge coordinator, nurse in charge, therapists, doctors who saw the patient/know about the patients and one consultant and registrar The main points here are:
1. Why has the patient identified as medically fit from the morning huddle not been discharged? What can the team do to expedite the discharge
2. Do the unwell patients from this morning have a clear plan
3. Do all patients have escalation plans?
ADAVANTAGE OF THIS:
1. Patient flow is maintained by ensuring medically fit patients are discharged/seen by therapists appropriately.
2. The nurse in charge knows about all the patients
1300 to 1500
The junior doctors do the jobs which include:- Chasing investigations
- Chasing referrals
- Cannulas, bloods
- Any procedures
- Discharge summaries
- Doing a quick summary of patients transferred to the ward after the consultant ward round and letting the consultant/registrar know so that they can do a senior review ( some patients are already seen by consutlants in the other ward in the morning and if they are stable, they do not need to be seen by a consultant again unless they are unwell). Do any jobs from the ward round for these patients
- Talking to relatives and updating them
-If free, joining consultants in their afternoon clinics
- Attend any teaching sessions
1500 to 1600
The junior doctors meet up and see what is outstanding. They can meet up in the doctors mess or the doctors office in the ward. They distribute jobs and ensure everything is sorted1600 to 1645
At 1600, all patients should have been sorted.The discharge summaries for patients who are medically fit but awaiting therapists input/transfer to rehab ward/ other specialist hospitals should be completed.
The electronic handover should be completed.
The consultant should come at 1600 to just do a quick review of any unwell patients and ask the junior doctors if they need any help.
Ask the nursing staff for any outstanding jobs like writing any drug charts, reviewing any medications or any concerns they have.
1645
15 minutes till home time! All jobs should be completed by now and a list should be made for handing to the on call team with a SBAR as explained here:https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html
1655 TO 1700
Handover to the on call team. If it is for a registrar review, the experienced SHO/ registrar should be handing over to them.Cases like :
1. Unwell patients
Example:
This 90 year old gentleman who is for ward based care, was medically fit after being admitted with a fall secondary to a postural drop has now developed a HAP. His EWS is 8 because he is on 6 liters of O2 (ABG shows type 1 RF), we started on IV antibiotics ( on the basis of high WCC, CRP, consolidation on CXR) , high HR ( Fast AF on ECG with normal BP - we have given beta blocker). We have informed the family that he is unwell and they are aware that he is for palliation if he deterioates.
You do not need to do anything yet but just be aware that you will be called about him later on if he continues to deterioate. He is currently comfortable.
His NHS number is.... , his date of birth is.... , his name is.... , he on ward..., bed....
If it is for chasing bloods, anyone can handover but with a SBAR,
S: 85 year old, admitted with chest infection
B: CKD, baseline eGFR 30 , frail, for ward based care, HTN
A: his renal fucntion declined today with high potassium. We have discussed this case with the renal team - he is not for dialysis. His pH is normal, he is not on oxygen. His potassium was 6.9 with no ECG changes, eGFR of 20 now. We have given salbutamol nebs, dextrose insulin and he on treatment- IV fluids, catheterized with good urine output, witheld nephrotixics. Can you repeat a VBG and serum electrolytes at 1800 please? The nurse on the ward can also do bloods and she is aware but in case she is unable to, she will bleep you.
ADVANTAGES OF THIS SYSTEM
1. Doing a SBAR way of handover helps the on call team who does not not know the patient understand what is required
2. Escalation plans are important for the on call team - DO NOT LEAVE THIS TILL THE LAST MINUTE!
3. All unwell patients and outstanding jobs are handed over appropriately.
4. The doctors DO NOT need to stay beyond 1700 chasing investigations - this is why we have on call doctors.
SOME MORE TIPS
1. Identify understaffing early - sometimes you need to take this up youself. It does not matter if you are a FY1, SHO, registrar, consultant. If you have access to the rota, it helps decide about the week ahead. When I was a CT1, a fellow GPST1 use to make the rota for the nect week ensuring all colleagues got the following- 1 admin day / half admin day a week
- Were not overwhelmed with a lot of patients as she made sure the rota was well staffed
She learnt:
- Excellent leadership skills
- She learnt this hidden talent she had and continued doing this in her GP practice.
2. Identify problems and work on a solution - turn it into a QIP.
If your trust does not have a rota for the entire duration, maybe talk to colleagues, see if it will help, liaise with management and make improvements. Again, it does not matter what level you are at.
3. Come and leave on time
You are paid to work for the contracted time. If you have to stay beyond this, exception report it :
https://www.bma.org.uk/pay-and-contracts/working-hours/work-schedule/exception-reporting-for-junior-doctors
4. It does not mean you are some kind of superhero if you stay 2 hours late everyday. You are at high risk of burning out. And you will evenutally burn out and will have to take time off with stress. Your mental well being is more important than anything else. Ensure you do everything possible to leave on time
5. Be organised. Not only at your workplace but in life in general:
http://omarsguidelines.blogspot.com/2018/02/the-importance-of-being-organized.html
6. Take care of your colleagues. If you are the registrar and see a FY1 struggling with 5 last minute discharge summaries, help! It does not matter what level you. If you are free, help. Your colleagues are your family! Take care of them. The FY1 of today is the SHO of tomorrow and will soon be a registrar - this kindess and compassion will continue down the line.
7. Ask for help. Taking everything upon yourself is not a good idea. It is okay to escalate understaffing to the consultant/ management.
8. Communicate with your nursing team. Update them regularly. Ask them at 1600 if they need anything
http://omarsguidelines.blogspot.com/2018/01/nurses-in-nhs.html
SOME MYTHS:
This is wrong! Every extra minute spend at work is less time spent unwinding after a hard days work, less time with your family - this makes you stressed and you will eventually burn out.
If I exception report, my consultant will hate me!
Consultants are responsible for the ward. Hence all exception reports come to them. Yes, it is lengthy however with time and experience, it is not difficult to fill them. It takes 5 to 10 minutes to fill it. 5 to 10 minutes to ensure management is fedback about a doctor spending longer than his/her contracted time at work to ensure it does not happen again is worth it. If they complain, you can escalate it :
https://omarsguidelines.blogspot.com/2020/01/bullying-and-stress-in-nhs.html
I am a non trainee and I have been told I cannot exception report
You need to take this up in your junior doctors forum, talk to your colleagues and maybe arrange a meeting with the directorate.
You, as a non trainee are seeing the same patient cohort as trainees and are expected to perform at the same level. Hence you should have the same support. You need to be a bit proactive here and ensure you are able to escalate it together to the right people.
You will be doing this job for the next 40 years or so. Just imagine you do this everyday - eventually you will have other committments like family, friends. Imagine you miss out on all of that because this has become routine for you. You are bound to get burnt out.
This is why we have on call teams - they are paid to chase outstanding stuff from the ward jobs
Asking them at 1600 if they have any outstanding jobs helps. Jobs like
4. Escalation plans
5. Unwell patients
Of course, if a patient becomes unwell at 1645 , you have to see them ( bleep the registrar at the same time) and make a plan. With a registrar , it will not take long. I as a registrar take around 30 minutes to manage an unwell patient ( A to E assessment, investigations, discussions with the family , handing over to the on call team). Us registrars do it all the time. We get used to this with experience and manage this faster. I am in no way suggesting that the junior doctors should not get involved at all - this is how they will learn but they do not need to stay beyond 1700 when a registrar can easily manage an unwell patient.
Hopefully, they will be able to leave in 15 minutes. It does not take long for us to manage unwell patients and we suually handover to our registrar colleagues on call quickly.
Please take care of yourself, you will be spending 60% of your life at work. Make your work as easy and as less stressful as you can. It is not easy being a doctor- looking after unwell people all the time. But with proper planning and support, we can improve our mental well being. And remember, happy doctors equates to better patient care. You matter! Your mental well being matters!
Of course, there will be some rare occasions on which you will have to stay beyond 30 minutes once a month which is fine - but it should not become a habit!
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