1. How much time do doctors spend looking after children in South African Emergency Departments?
Project Aim
To measure the average amount of time per patient doctors spend providing care to children less than 13 years old who present to emergency centres in the Western Cape.
Project Design
Cross-sectional, observational study applying Time and Motion methodology
100 patients – sampled by convenience – at two emergency centres over December 2015 – January 2016
The Fellow observed and timed the initial assessment by the first doctor to attend each child
Continued to observer the doctor as they conducted any investigations, discussions and documentation related to the patient. If other doctors become involved in the care of the patient, the Fellow also recorded their activity.
In this way, the Fellow sought to record, to the nearest second, any activity by any doctor related to care of the selected patient, defined and categorised by pre-specified criteria.
Interim Results (n=87)
Impact and Sustainability
To our knowledge, study is the first of its kind, anywhere in the world
Builds towards the development of an evidence base for efficient staffing of emergency centres
Interim results suggest that the DoH benchmarks underestimate time spent by doctors in actual practice
Statistical analysis is underway. Early indications suggest differences significant at a 95% confidence level
Final results will be presented to the locally-involved Departments, and the Health Impact Assessment Unit, Western Cape Government: Health. We intend to publish the results to maximise their impact.
We envisage that our data will for the first time permit initial development of an evidence-based model for emergency department staffing in the Western Cape, and perhaps even beyond
In turn, this will permit more efficient deployment of limited healthcare resources, so that these resources can “do the most for the most”
Our data also provides a baseline for quality-improvement work aiming to improve efficiency in this setting – providing a reference point to evaluate progress through PDSA cycles, for instance
This month, a new IGH Fellow joins the team, with scope to take these ideas forward locally
Lessons Learned
Through and extensive project-planning process required to satisfy the local regulatory framework:
This included construction of a detailed 43 page proposal and supporting documents, approval by several different ethics committees, and presentation to multiple departments
Though at times this felt frustrating, the long and systematic planning period undoubtedly allowed us to “hit the ground rolling” when the final approvals were in place
As a result, the actual execution phase of the project was straightforward, with no significant problems encountered, and with broad “buy-in” from those affected
Team
Dr Baljit Cheema: Paediatric emergency specialist, Emergency Medical Services, Western Cape Health. Senior Lecturer, Division of Emergency Medicine, University of Cape Town. Role: Assist with project design, literature review, data analysis and write-up
Dr Andrew Redfern: General paediatrician, Emergency and Ambulatory Unit, Tygerberg Children's Hospital, Department of Paediatrics & Child Health, Stellenbosch University. Role: Assist with project design, literature review, data analysis and write-up
Dr Robert Stellman: Paediatric registrar, NHS London Deanery, United Kingdom; NHS IGH Fellow, Western Cape Government: Health. Role: Construction of project proposal; data collection; data analysis, write-up of results
What was Done and Why
High quality, safe care for children at emergency centres requires adequate staffing
But little consensus on how adequate staffing levels should actually be determined
One logical, evidence-based approach would be to directly observe how much staff- time is actually deployed per patient, in practice
Such studies surprisingly sparse, particularly outside of the high-income nations
The Western Cape Department of Health simply uses estimated benchmarks, which
do not define the patient classification used,
do not map it to current “SATS” triage categories (see diagram),
do not distinguish between adult and paediatric patients
We proposed to try and fill this gap in the evidence by
generating highly reliable, high-resolution data on the amount of time doctors spend providing care to the paediatric patients
through application of Time and Motion methodology: independent and continuous observation by a researcher of the doctors providing care to each patient included in the study.
Time and Motion = independent and continuous observation of people at work
Lesson Learned: Time invested in careful project-planning and stakeholder-engagement before work commences, can help reduce the risk of issues arising once work is underway.
This might map – for instance – to an audit project on an NHS ward: it would be important to have a clear, written plan for the audit, and the involvement of ward staff, well-before data collection actually starts.
Complexity of observed activity meant we were faced with recording to paper and then transcribing huge amounts of timing data: difficult, extremely time-consuming, and, worse, highly prone to error
Through reviewing the existing scientific literature, we discovered software specially designed and validated for the timing of medical staff activity, constructed by the Australian Institute for Healthcare Innovation (pictured)
The Fellow therefore reached out to the Director of the Institute, and was able to negotiate for fee-free use of the software in this novel context
Valuable not just because it made data collection much more accurate and efficient, but also because it represented new international collaboration and shared purpose between the Australian centre, our local South African partners, and of course the IGH programme
Lesson Learned: Technology can be harnessed to produce huge improvements to a process, but often comes with technical, financial or other obstacles attached. Partnerships can help overcome some of these barriers.