Quality | 2009.11.04
Poor handovers and working time directive 'causing hospital deaths'
• Shorter hours affect care, says confidential inquiry
• Report reinforces worries over surgeons\' rotas
Poor communication between doctors, inadequate handovers at night and delays in contacting consultants are causing unnecessary hospital deaths, a confidential patient care study warns today.
The highly critical report exposes substandard decision making and a lack of involvement by senior clinical staff in the treatment of patients who died shortly after being admitted.
Published by the government-funded National Confidential Enquiry into Patient Outcome and Death, the 116-page investigation of more than 4,500 fatalities will reinforce anger among surgeons over the impact of the European working time directive on medical rotas.
Researchers found that in 25% of 1,635 deaths studied in detail – 407 cases – there was "a clinically important delay in the first review by a consultant".
Two case studies involving teenagers who died highlighted the failures to consult senior medical staff early on. In the first, the youth should have been operated on to remove the flesh-eating bacteria necrotising fasciitis.
"There was no senior surgical input and no action was taken," the report said. "The patient deteriorated over the next 12 hours and died without further surgical review or intervention."
In the second case, a teenage victim of a road traffic accident died after a tube became blocked. "With senior involvement at an earlier stage, clear diagnosis and a decisive management plan, could this patient have ... potentially avoided this outcome?" the study asked.
As well as highlighting individual failures of care, the study is critical of the EU working time directive.
The final stage of the directive came into force on 1 August. It has been introduced progressively, bringing down doctors\' hours. The Department of Health has already given some surgical teams temporary opt-outs due to the difficulty of complying with the shorter working week.
The report suggests the shorter working week is responsible for a lack of continuity in out-of-hours care and a reduction in training opportunities for operating theatre staff. "Unless there is evidence underpinning a political will to challenge the directive through the European parliament, other mechanisms must be developed in order to address the lack of continuity of out-of-hours care and the availability of appropriately trained staff, 24 hours a day," the report, Caring to the End?, says.
"Not only were trainees less frequently in theatres, but when they were, they were not receiving direct supervision at the operating table. This raised concerns that trainees are not getting quality training in emergency surgery. It also raises the question about the levels of assistance available for consultants operating without any trainees in theatre."
The inquiry looked at a sample number of cases from 2006-7 where patients had died within four days of admission to hospital but its report does not make any estimate of the number of deaths that might have been prevented.
Of 1,983 cases, researchers found 13.5% – 267 cases – showed "poor communication between and within clinical teams identified ... as an important issue".
The "poor decision-making" and "lack of senior input" were a particular problem in evenings and at night, the report said.
More than 60% received good medical care but a third of patients did not, the report found. Many healthcare professionals did not have the skills required to care for patients close to death, it added.
Ian Martin, a maxillofacial surgeon in Sunderland and one of the report\'s authors, told the Guardian that shortening rota hours had led to more shift changes between medical teams and greater chances for mistakes to occur "unless you set aside a lot of time for handovers".
The resulting "fragmentation" of medical teams, he said, meant that in some cases urologists, who specialise in urinary tract disorders, for example, were left covering for ear, nose and throat doctors.
Martin said: "We haven\'t found any evidence … that working up to 60 hours a week [caused] fatigue. We now have the situation where consultants are operating on their own at night but trainees are no longer there to learn how to operate on emergency cases."
In one trenchant passage, the study says: "Continuity of care and an understanding of the case throughout the patient\'s hospital stay must be assured.
"Change in the hospital team structure over recent years has seen individual clinicians become transient acquaintances during a patient\'s illness rather than having responsibility for continuity of care.
"Staffing arrangements and shift working have also been shown to be disruptive and with the implementation of the [directive], this disruption is likely to continue and to impact on the training of tomorrow\'s doctors."
John Black, the president of the Royal College of Surgeons (RCS), welcomed the findings.
He said: "This hard hitting report highlights the loss of proper team-working in UK hospitals, resulting in dangerous failures of communication which make it harder and harder for clinicians to provide safe care for patients.
"The RCS has been warning for some time about the dangers of multiple handovers."The problems revealed in this report date from 2006 and 2007, when the NHS was already struggling to meet the demands of a 56-hour working week. Now that in theory everyone in the NHS is working for only 48 hours the situation in the country\'s hospitals can only have worsened.
"Earlier this month the [RCS] published a survey into the early effects of the 48-hour European working time limit on surgeons and found that these new rotas had almost entirely removed adequate time for handover of sick patients," he said.
Earlier this week the Association of Surgeons in Training and the British Orthopaedic Trainee Association reported that there was "growing alarm" among junior doctors over the impact of the directive on surgical training and patient safety. They said that "67% of surgical trainees are attending work while off-duty to protect their training and gain adequate experience operating".
The Liberal Democrat health spokesman, Norman Lamb, said: "It\'s of huge concern that so many of these patients are not being diagnosed as being close to death when they arrive in hospital. We urgently need to look at the way that doctors are assessing patients.
"Rather than forcing doctors and nurses to jump through hoops to meet government targets, we should be giving them time to treat every patient with the dignity they deserve."
The Department of Health said: "Our overriding priority will continue to be ensuring that patients experience high quality, safe and effective care in the NHS.
"Hospitals such as the Homerton in London, [which has] been working a 48-hour week for over two years, have produced evidence that shows the change has decreased hospital mortality. There is no evidence of harm being caused to patients. "In fact, the independent regulator responsible for junior doctor training said there is evidence the [directive] improves patient safety but little evidence that it reduces the quality of training. "We have set up a reference group, which includes the RCS and other interested parties to provide advice on ensuring rotas are compliant [with the directive]. Working together with the local NHS and the royal colleges we have set up a rigorous quality assurance process to give us an accurate picture of how [the directive] is being implemented and so we can provide support where it is needed."
For more information, please visit
http://www.guardian.co.uk/society/2009/n[...]onfidential-patient-care-study
