Easing winter pressures

Winter pressures have been a feature of the NHS for the past decade and are a costly problem. Emergency admission rates increase year on year, complexity of illness also increases together with frailty but bed numbers and staff do not increase.

At University Hospital Southampton Foundation Trust we introduced consultant-delivered multidisciplinary team working (CD-MDT) with outstanding results, including reduction in acute length of stay, increased patient and staff satisfaction, significant reduction in hospital deaths and a reduction in the number of patients who died within 30 days of discharge.

‘Many of these tasks are more effectively delivered by a consultant and non-medical team’

In winter 2011-12, the trust introduced a winter pressures team, delivering consultant inpatient medical care without trainee doctors. Evidence shows that the main components of medical inpatient care consist of decision making, administrative tasks, managing investigations and discharge planning. In principle, many of these tasks are more effectively delivered by a consultant and non-medical team, rather than the traditional team model of junior doctors/trainees supported by a consultant.

The main aim of the project was to develop and test a sustainable and safe model of consultant-delivered inpatient medical care, supported by a specialist nurse, a medical assistant and a pharmacist.

Differences in outcomes

This is a cost-neutral model when compared with the traditional team of one consultant, one specialist registrar, one junior doctor and one foundation doctor. We also studied the impact on work and practice members of the team, patient outcomes and impact on other ward staff and medical teams.

We planned medical care of inpatients around rapid and focused decision making, with better outcomes (mortality, readmission rates), more efficient use of resources and increased productivity (acute length of stay, use of diagnostics and reduction of risk), improved access for a GP to a fully trained doctor, patient expectation of access to a skilled clinician and benefits for junior doctor training. In order to achieve such a multifaceted goal, we c

hanged our service model and consultant practices.

The winter pressures team consisted of a consultant physician, a band 6 nurse, a band 8 pharmacist (0.5 whole time equivalent) and a medical assistant (0.5 WTE). The work consisted of daily morning ward rounds with consultant availability on site during office hours.

The main differences between the winter team ward rounds and those of a traditional consultant team were that the consultant was an integral member of the team, not just the decision maker who would not influence the actions resulting from the decisions.

As a consequence, there was strong team identity and clarity about division of tasks. All team members took responsibility for the daily and more long-term action plan arising from ward round decisions.

The tasks arising from the ward rounds were shared among the team as appropriate: for example, prescription of medication was carried out by the consultant or prescribing pharmacist; urgent canulation or phlebotomy by doctor, nurse or medical technician; family communication by nurse or consultant; search for elusive equipment by any member of the team.

The patient cohort was general medical patients aged under 80, triaged to general medicine in the medical assessment unit. In our organisation, all patients are admitted to medicine via AMU (source GP or ED) and managed by AMU staff until transfer to wards. Their care was then taken over by CD-MDT on a geographical basis within the hospital. The project ran for six months and outcome data was compared with a traditional medical team, with comparable patient numbers, demographics, reason for and route of admission to hospital, and discharge diagnoses. There were marked differences in outcomes (see table above). This model is sustainable and reproducible; it improves patient care and satisfaction, and staff feel valued.

The winter team

The general attributes required for the team are commitment, flexibility, in roles and working, strong leadership and robust communication. Individual and collective reflection on the evolution of the team is essential and adjustments in clinical practice must reflect team evolution. A number of individuals had the opportunity to work as part of the CD-MDT.

The consultant

The role of the consultant differs from the traditional role for a consultant physician and it provides continuity of patient care, effective daily clinical decision making, effective use of resources and effective discharge planning.

This challenges the consultant job plan in many settings: to be available throughout the working day; to be confident in managing acutely deteriorating medical patients; to work autonomously; and to reacquaint themselves with junior doctor tasks are the key elements of success.

As part of the consultant role, there are also huge opportunities to shape the organisational future: to mentor allied healthcare staff; to engage with clinical support services to obtain better care for patients; and to work within the MDT.

The challenging aspect of this post includes decision fatigue, the need to be available throughout the working day and to work autonomously.

The nurse

The CD-MDT nurse acts as the team coordinator, including discharge planning, but the nurse also contributes significantly to clinical decision making on ward rounds. Organisational experience and clinical confidence are essential to fulfil this role. There is potential to develop this role into that of a nurse practitioner to reduce consultant clinical workload, although care must be taken not to create an alternative version of a junior doctor.

The medical assistant

The medical assistant has several vital roles in the team: to support patient care with practical procedures, such as ECG, canulation, phlebotomy; to be available in an emergency, managing investigations - blood forms, liaising with radiology, chasing results, and to act as team coordinator/leave cover for the team nurse.

The administrative role and contributions to discharge planning can be developed within this role. As the project progressed, it became clear that many of the administrative tasks traditionally carried out by doctors could be carried out by other, less expensive, members of the healthcare team.

The main barriers to rapid implementations are current governance structures. A good example of this would be limited access to electronic diagnostic applications and electronic patient documents.

The clinical pharmacists

The role of the clinical pharmacist is invaluable. Medicines reconciliation, medicines advice and therapeutic monitoring become an integral part of daily work and reduce the total number of pharmacy interventions by half. 

When compared with a traditional consultant ward round without a pharmacist present, the CD-MDT rounds had half the number of pharmacy interventions (falling from seven to four per patient). This can be interpreted as fewer medication errors being made on the CD-MDT ward round. Therefore this model provides a safer and more efficient way of delivering acute healthcare.

The CD-MDT works best when there is consultant availability, leadership and proactive decision making by all team members. Maintaining momentum throughout the patient pathway remains a challenge, even when working with a small team of highly motivated healthcare professionals. To maintain patient safety, timely decision making, task completion, team work and efficiency, the total case load needs to be limited to 15-20 patients per team with a maximum of five new patients per day.

The CD-MDT can be developed in many ways: it can become a rotational post for consultant physicians. It would be suitable for training nurses and medical assistants clinically. It is also a very safe environment for mentoring of clinicians while delivering first-rate care.

Juliane Kause is a consultant in acute medicine and intensive care, Richard Fielding is a consultant general physician and nephrologist, Vanessa Arnell-Cullen is a clinical manager and Derek Sandeman is a consultant endocrinologist at University Hospital Southampton Foundation Trust.