1. Supporting the acute take

3. +28%
-23%
-38%

5. The Medical Registrar

6. Medical Training Flows 2013
CMT Expected fate
700
120
390
Non Medicine Training GP
Other
Leave Medicine
Training break
‘previous CMT at some point’
No training break
‘Never CMT’
260
700
300
ST3 Expected source
Predicted vacancy = 280 posts

8. Solutions - Workforce Increase number of CMTs to fill vacancies
Divert funding from locums to training posts including LATs
Expand MTI scheme

9. Solutions – Organisation of acute take
Ensure adequate support teams – stop the scut!
Employ specialist nurses and physician associates
Involve medical specialties early
Use intelligent rota design (blocks)
Ensure team adequate (2 registrars)
Broaden access to the acute medical take……..

10. Solutions – Broaden access to acute take
All doctors who have PACES and have completed CMT should have the competences to be a medical registrar
44% of these do not feel they are prepared to be a medical registrar
Involving single specialty registrars needs careful planning and involvement of LETB/dean
Specialty training must not suffer
Participation for non-GIM registrars should be restricted to in the first months

12. Workload
Teamwork
Interactions with other teams
Training and supervision
Recruitment and retention

13. Solutions - Workload
There should be a named consultant physician who ‘champions the medical registrar’
There should be a hospital manager responsible for assessing the roles and responsibilities of the medical registrars
Use the RCP ‘roles of the medical registrar’
Free up the medical registrar from non-priority jobs

14. Solutions – Interactions with other teams
Clear mechanisms for referring patients under non-medical teams to medicine in and out of hours
Set up ‘buddy’ arrangements between medical teams and surgical wards
Clear definitions of which primary presenting complaints are admitted under which team
Referrals should be made by adequately experienced staff

15. Solutions - Training Routine and regular
Consultants directly observing ward rounds lead by the registrar
Feedback of clinical outcomes to admitting registrar (e.g. discharge summaries)
One-to-one meetings with supervising consultant (not just specialty)
Attendance by registrar on post-take review of patients they have been involved with
Formal procedural training easily available (including simulation)

16. Solutions - Other Chief resident Local Faculty Groups
Inspirational leadership

17. References

18. local
Currently, there is a shortage of dually accrediting trainees and of trainees in acute medicine.
Asking doctors who are currently training in a single specialty to support medical registrars who are formally dually training requires careful consideration to protect patients and trainees.
To be consistent with best practice, any trainee undertaking such role will require proper notice, appropriate induction, training, consultant supervision, and feedback, with a clear plan in place to protect speciality training.
GSTT have 171 medical registrars from the LETB
There are numerous other qualified trainees in various Trust posts- these are more difficultt to identify on HR systems but can be utilised in the second tier of cover for the wards.
Currently only 12 are involved in the acute take and other are on call for various sub specailty work.

19. Local Single specialty registrars -collaboration with trainees,
Training Programme Directors
Heads of school.
The final decision must involve the postgraduate dean.
Participation in the acute take should enhance their overall training and not be detrimental to specialty training.
Many of the key competencies and skills acquired during participation in the acute take are equally relevant to speciality training and should be counted towards training.

20. Considerations
The more recently a doctor has left core medical training, the safer requesting them to contribute will be for the patient, the employer and for the doctor.
Participation of non-GIM registrars in the acute take should usually be restricted to the first months for most trainees

21. Local
The current cover at St Thomas hospital consists of 1 registrar overnight.
Aim to cover the nights with 2 registrars, 
SpR1 covering acute admissions and the 2nd covering the wards.
This would create a rota which would not impact too much on day work and other non resident on call commitments. ( Most already are on call for their specialty from home)
Most of these doctors already have banding and so the cost implication would be about 8 extra posts being banded which currently do not attract banding( allergy and rheumatology)
As many SpRs would be incorporated to ensure that specialty training is not compromised

22. Medical Specialties Summary
Band
Number available
Numbered posts
Current out of hours commitment
Acute Med 3
On GIM rota
Allergy
none 4
Not banded
Cardiology 11
Already resident on call rota including PAMI
Clinical genetics
No on call – have been out of GIM for some time
Clinical oncology
Already do non resident nights
Clin Pharm 2
2 on gen med rota
Dermatology 1B 9
On site till 8pm weekdays, Saturday morning
Could do nights, would need OFF days
Diabetes and Endocrinology
4 (but 6 on diary cards 6
Speciality: Weekend 12-4 resident
weekdays resident till 7
Gastro 1A
6 on diary card
Non resident on call – bleeding rota
weekend ward round
Could do nights but not many hours free – would need OFF days
GU medicine 7
Weekdays till 9
Weekend days
Includes HIV as SPRs are shared
Geriatric medicine
5 on diary card
Rest – weekday evening
Saturday 9-3
Haematology
Infectious diseases ?2
1 placed on ITU and included on ICU rota
2 on Infection non resident on call rota
Med micro/viro ?6
1 placed in GIM and on GIM rota
6 on Infection non resident on call rota
Med Oncology
4 (+3 fellows)
Med Ophthalmology 1
Covers ophthalmology emergencies. Weekdays 5-9pm resident, 9pm-9am non-resident
Weekends 9-5 resident, 5-9am non resident
Neurology
Weekend days 10-17
Palliative care
1 in 5 weekend on-call rota (non-resident) covering 48 hours Saturday 9am to Monday 9am.  Cross-site covering GSTT and KCH.
Renal 5
Non resident nights and weekend days guys site
Respiratory
varies 8
3 on gen med rota
3 on LFU weekend day rota – not many hours left
2 on ITU rota
Rheumatology
1 on gen med rota
3 not banded

23. Extra training and support
Specialty trainees to be appropriately supported
This can be with appropriate teaching sessions ( available with our GIM training programme for ST3 and above)
To match any skills needs in simulatiuon inc leadership, Handover & SBAR
And to develop leadership especially in handover which is currently being supported as a trust priority

24. For trainees support we will ensure
For trainees support we will ensure
1) How to utilise single speciality junior trainees with MRCP in a safe and effective manner to broaden the acute and emergency cover arrangements by supporting the system and not be the front line registrar.
2) Support structures and educational resources for these individuals require will be identified and supplied eg ALS
3) A specific educational advantages for these trainees that relate to their speciality training
4) It will strengthen the Hospital at night and Hospital at Day teams

25. Standard Operating Procedure Medical SpRs at Night
1) Carry 2291 (Ward bleep) 20:30 to 08:00
2) Attend Hospital at Night handover at 20:30
3) Respond to cardiac arrest and emergency calls without expectation to led the resuscitation when the full team has arrived
4) Review ward patients referred for medical opinions from other specialties
5) Review acutely unwell patients under medicine and those referred from other specialties, with the support of the SNP team
6) Supervise FY1 in their ward duties in the North wing wards, and the CMT/GPVTS/FY2 in their ward duties in the East wing
7) 09:00 to 09:30 handover any patients seen overnight or awaiting further review to ward teams
Accountability:
During a shift 1st and 2nd SpRs are clinically accountable to the Medical Consultant on call and in addition:
Responsible To: Dr David Wood, Service Lead General Medicine
Accountable To: Dr Richard Leach, Clinical Director for AM & ED
Management Support: Mr James Watts, Service Manager, AM

26. Impact on current SpRs
The rota - 8 specialty days lost every 12 weeks.
Training days are organised in simulation - in line with the training needs identified for those on the rota.
The role is predominantly ward cover with the support of the 1st on call Medical SpR and SNP team. The 2nd on call SpR would not routinely be expected to clerk patients,
The 2nd SpR role will in time hopefully allow a more formal ward handover to take place. Hours are 20:30 to 09:30 to allow time for morning handover to teams as needed.

28. Effective Communication – Reducing error
Closed-Loop Communication
6. Communicate
5. Do
Sender
Action Performed A
Receiver E D
1. Think
4. Understand C
2. Speak
3. Hear B
Transmission
Anticipate potential conflicts of tasks – avoid?
Raise concerns
Check for understanding
Receiver
Active listening
Check your understanding
What is meant is not what is said
What is said is not what is heard
What is heard is not what is understood
What is understood is not what is done
What is done is not what is communicated
Where it goes wrong
Identify yourself
Explicit – what you want, when you want it
Check receivers ability and understanding
Check, challenge, clarify
Report back when task is complete
Effective Communication – Reducing error
© SaIL Centre March 2014 28 28

30. IDENTIFICATION – grade, specialty, skills
Present
Past
LEADER
Future
Anticipated RISKS, READ-BACK, Rationale

31. Night Team functions Powerpoint presentation: A more didactic talk on the night team and specific consideration of the role of the 1st and 2nd on Medical registrars, as well as an overview of the critical care response team.

32. Registrar training
Scenario-based discussions: This is designed as an interactive workshop using a few common presentations to demonstrate particular features of the system at GSTT.
 3 Hi-fidelity, fully immersive simulation scenarios: End-of-life care in a patient with severe COPD; Acute life-threatening upper GI bleed; Acute agitation with alcohol withdrawal and attempt to abscond.

33. OBJECTIVES AND HOW THEY WILL BE MEASURED
Performance Measure
Increased delivery of safe care
Patients seen more quickly on the wards
Increased learning opportunities for trainees
ARCP curriculum mapping
Improved handover of patient care with senior trainees
Handover Electronic data compliance
Strengthened night
Fewer deteriorating patients/ appropriate follow up
Spread good practice
Uptake at Guys site and in other hospitals with similar problems
Increased ST with dual accreditation
Workforce increase in consultants

34. Deliverable
A rota strengthening
trained ST from single specialties trained and supervised
Expansion of GIM training programme to single spec trainees
Liaison with head of school and local faculty leads