It's a  tricky one. Unsafe department you need to do something about. Also I think you've got a bit of a duty to look after your team.

Your job plan ought to cover this kind of thing. Where I would be extremely wary about having coming in for waits in your job plan is that if calling the consultant in is a possible response it tends to be the only response. So the response to chronic understaffing is to call the consultant in more. The response to lack of beds in the hospital is to call the consultant in. The response to lack of nurses is to call the consultant in. It's not good for the patients when this happens because you often get the consultant coming in and not being able to do anything but what actually needs to be done doesn't get done. The 4 hour target has its pros and cons but it does give us a bit of leverage. If we're understaffed or there are problems clearing patients out of the department it creates a bit of an issue for the hospital so they have to look at how to sort it (without the 4 hour target it's still an issue, but the target makes it a  higher priority). You don't want the only solution to be to call the consultant in more.

How we have dealt with it is our job plan says we don't get called in just for waits. What actually happens is we do sometimes come in just for waits. You get to check  your team, make sure people are taking breaks, work out what actually needs to be done on patients being referred, maybe clear the box to a manageable level. Basically leave your team feeling they maybe can get on top of it. It seems to work pretty well and we don't get called about waits all that often. And when we do get called it is explicitly to inform us rather than to call us in. (If we choose to come in, that is a personal decision)

The other big point I'd make is that coming in for the sick patients at night is a bit of hassle on the getting out of bed side but the work itself is fun. If you're coming in all the time for waits you're just not going to have the energy to come in for the sick patients as well. So the job gets more boring and less pleasant (it's also high stress as by definition you're doing a lot of your work when the department is over stretched). As a specialty, we're currently recruiting about half the registrars we need and for every 4 registrars we recruit one consultant emigrates. We can't afford an avoidably high level of burn out on top of that.

Btw, on Rowley's point on work after 7 pm being voluntary: that's the case for scheduled work. Getting called in after 7 pm is not voluntary. Although I'd guess if the hospital pushes it on having coming in for waits in your job plan and mediation and appeal go against you, that's a backup plan: if they insist on coming in for waits, you're not going to do scheduled unsocial hours as well (provided you have followed the BMA advice and when agreeing to scheduled unsocial hours, made it explicit that you have the option to drop it at 3 months' notice should you so choose).

Matt Dunn

> -----Original Message-----
> From: Accident and Emergency Academic List [mailto:ACAD-AE-
> [log in to unmask]] On Behalf Of McCormick Simon Dr, Consultant, A&E
> Sent: 11 November 2013 09:50
> To: [log in to unmask]
> Subject: Waits at night
> 
> This old chestnut is rearing its head for us, particularly as, for us, there are
> more breaches of the four hour standard happening at night.
> 
> There is pressure being put on us to be called back when the wait to see an
> ED clinician gets to 90mins...regardless of acuity.  We already have an
> escalation policy that encourages the nurse in charge to call the consultants
> back should certain categories of patients be waiting certain lengths of time
> OR if they feel the department is 'unsafe'.
> 
> We have pointed out CEM guidelines:
> 
> When on-call, an EM consultant should not be recalled to hospital solely to
> deal with a build up of less serious cases, because of excessive waiting times
> for first assessment or because of potential breaches in the DH operational
> emergency access standard ("4 hour target").
> 
> Each ED and hospital as a whole should be staffed and resourced to a
> sufficient level to manage what are predictable peaks in workload, 24 hours a
> day, seven days a week. Where this has not been adequately addressed by a
> Trust, the on-call EM consultant must not be expected to make up for any
> deficit in staffing or other resource.
> The decision whether to return to the ED or not, is one of a clinical,
> professional nature and should be a personal decision, made by the on-call
> EM consultant, in full possession of all relevant contemporaneous
> information. It is not appropriate for a manager (clinical or non-clinical) nor
> for a clinician in another specialty, to make this decision.
> 
> 
> ...but we have been told in no uncertain terms what are thought of these by
> our management team.
> 
> Are we out of step in standing by the College guidance, are others in this
> position coming in to clear waits, OR are there colleagues standing up to this
> and will the College back us should we refuse to comply?
> 
> Your advice and observations would be appreciated.
> 
> Simon
> 
> 
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