Postgraduate School of Anaesthesia Quality Management Visit to North Devon Hospital

 

26/11/2014

 

 

 

 

 

Postgraduate School undertaking visit: School of Anaesthesia and Intensive Care Medicine

Primary author of the report (name and job title): Dr James Pittman, Head of School

Date(s) of visit: 19th November 2014

Visit team (names and educational job titles):

Chair

James Pittman HOS

Panel member 1

Mel Hearn TPD CT

Panel member 1

Jane Bunce Quality Manager HESW

Medical externality

Ted Rees HOS Severn School of Anaesthesia

Ley representative

Mr Bill Wylie

Programme

No. of trainees seen

No. of trainers seen

Anaesthesia/ACCS

8

12

Evidence considered prior to review taking place: GMC survey, ARCP feedback, submitted files of department guidance for trainees, rotas, teaching programmes, departmental presentation of current training objectives.

Date visit report ratified by Quality Team

28th January 2015

Date visit report made available to provider

29th January 2015

Date provider ratifies visit report

12th February 2015

Circulation of this report: Peninsula Postgraduate Medical Education Quality Team, Director of Medical Education

 

Executive Summary

North Devon District Hospital (NDDH) provides acute hospital services to the people of North Devon and neighbouring towns and villages in North East Cornwall and Mid Devon. The trust serves a core population of around 165,000 people. Greater than 20% of the population are over 65 years old and nearly 10% are over 75 (UK averages are 16% and 7.5%, respectively).

The Anaesthesia and Critical Care department currently has 13 consultants with 4 new appointments starting imminently. There are 4 associate specialists and 7 middle grade trust doctors. There are 7 core anaesthetic trainees (one is currently LTFT) and 1 ACCS ED trainee working in the department. At least 90% of surgical lists are supervised by consultants. The department provides anaesthetic cover for approximately 10000 operations per year of which approximately 2000 are performed as day cases. There are 7 general operating theatres, 1 eye theatre and 1 obstetric theatre. The Obstetric unit manages approximately 1600 deliveries per year. The department covers a broad range of surgical specialities. Tertiary surgical services are not provided and vascular surgery has been centralised away from NDH.

The Critical Care Unit in North Devon has 6 beds (4- 5 level 3 and 1-2 level 2). The unit is located near the operating theatres and in close proximity (the floor above) to imaging and the emergency department.  The unit is recognised for ICM training at intermediate level (Grade 3). Eight consultants cover the on call rota. There are approximately 400 admissions a year. In 2012 the unit admitted 220 level 3 patients and 180 level 2 patients (total 1374 level 3 days). 70% of admissions are medical and 19% are following emergency surgery. The mean APACHE 2 score is 16.5 and ICNARC data indicate better than expected outcomes with a standardised mortality ratio of 0.78. 3.8% of admissions are transferred out of which 2.2% are for non-clinical reasons. The early readmission rate is 2%. The unit has 2 haemofiltration devices and up to 7% of patients receive renal support. 48% of patients are ventilated and 15% will have some form of advanced cardiac monitoring. All the visible equipment (monitoring and ventilators) appeared modern and well maintained. The unit participates in ICNARC and Cost Block Programme, receiving 15 hours funding for administrative support for this activity.

Anaesthetic training in NDDH has been a concern for the HESW Peninsula School of Anaesthesia and ITU. The GMC trainee survey and feedback from trainees at their ARCP’s have highlighted problems, including issues of clinical and educational supervision, adequate experience, patient safety and bullying. The department has received a GMC survey red flag for overall satisfaction in the last 2 consecutive years. They have also had a green flag for handover for 3 years running. The department is small and only has core anaesthesia and ACCS trainees. It is potentially less easy to deliver the many faculties of training in a small group environment. There are advantages though of being able to offer a closer relationship with trainees, tailored training, close supervision, less competition for learning experiences, as well as opportunities specific to NDDH such as patient transfers and simulation training.

 There has been a significant turnover of Consultants in the last year (almost one-third), with new appointees now replacing retirees.  This has meant a period of transition within the department involving the use of locum consultants and having less than optimal staffing numbers. The replacement consultants are now in or nearly in post and the department is regenerating itself following this time of change. This has generated improvements in the teaching environment, including the quality of educational supervision. The department is trying to tackle historical problems in the delivery of training.  New members of the team have combined with established consultants to improve the delivery of training. Key members of this team demonstrated great enthusiasm in this process and their hard work in beginning to make the necessary changes. Work remains to be done. The department has a challenging training environment but it is reassuring that the journey of improvement has started. 

 

Key recommendations

 

1

Trainees spend too much time in ITU during their 2 year rotation. Change the staffing arrangements for the 5-9pm  ITU on-call shift so that CTs can be in emergency theatre rather than ITU. Written handover of ITU patients is recommended, particularly for the evening shift. A structured ITU teaching programme should be developed. Review in 6 months.

2.

CT 2’s should undertake solo lists of an appropriate standard so they can gain confidence in independent working. Review 6 months.

 

3.

The CT teaching programme needs to be expanded and focussed on exam preparation. A review is needed of the teaching programme delivered to novice anaesthetists and the combined  CT teaching programme with Taunton, so that RCOA curriculum  is adequately covered.  Review 6 months.

4

Educational supervisors should have a minimum of 2 trainees each.  Review 12 months.

5.

Increase the performance related feedback to trainees, focusing on the strengths and areas that they need to improve, after they obtain their IAC. Immediate.

6.

Optimise the clinical opportunities made available to trainees so that they are on parity with other CTs in the region at the end of the 2 year rotation.  Review 6 months

7.

Display photographs of key staff in the department. 3 months.

8.

Departmental Information technology resources need to be improved. Review 6 months.

9.

Pain training needs to be developed. Review 6 months.

 Dr James Pittman

 

Areas of good practice

Department / Programme / Specialty

Area of good practice

 

 

 

Anaesthesia /ITU

 

Development of the M&M meetings

Trainee clinical and educational (?) supervision was good

Departmental  induction

Split consultant anaesthetic and ITU rota

Rotas appear to be EWTD compliant

Trust support of ES SPA time and time required for training/ teaching activities

 

 

Summary of the visit

Patient safety inc. handover and induction

Trust and department Induction was reported as organised and the information provided was considered reasonable by CT2s.  The CT1s described the Anaesthesia induction as one of the better ones they had experienced. It was reported that the induction included a tour by a current trainee and this was appreciated by the trainees. All CT1 trainees confirmed they had seen the Standard Operating Procedures produced by the department and that they had found these guidelines helpful. Trust Incident form reporting had been explained.

Generally speaking the trainees believed they received a comprehensive trust and departmental induction. One criticism of the online induction process is that it is good for the trust to audit who has completed it, but not good for the user as it has tended to get completed in their own time.  In the opinion of the trainees the departmental induction was well managed and with a useful information folder. There was a departmental tour and introductions although it was not possible to meet everyone.  All trainees met with their educational supervisors within the first few weeks of commencing in post.

ITU multidisciplinary handover takes place at 8.30am and the nursing staffs make up a formal handover sheet. An issue was raised regarding the variable nature of ward round/handover in the ITU, particularly in the evenings. There is an unfortunate 3-4 hour period in the evenings when trainees cover the ITU between day and night shifts staff. This appears to be detrimental to training and potentially patient safety. Written handover did not appear to occur at the handover in the evening.

There is currently no general anaesthesia handover, however the CT2 trainees carry the bleep. There is no trainee handover for obstetrics, despite the CT2’s being the first on call for any obstetrics epidurals. Core trainees are not part of the morning O&G handover but one does take place.  Trainers reported that they try to get CTs involved in the O&G handover if there are interesting cases.

Communication between the Core trainees and middle grade trust anaesthetist needs development. The trainees often did not feel they always knew what cases were going on in the evenings.

Trainees were happy they knew who was supervising them and how to make contact with their supervisors. Trainers were aware of whom they were supervising. Core trainees are well supervised in hours by consultants; out of hours there is always a middle grade in the hospital and consultant on call at home. Middle grades (Associate Specialists are mainly not on call, Staff Grades are on middle grade rota) are generally very clinically experienced.

There is a Split consultant rota –  one Anaesthetic consultant & one ICM consultant on call together.

The on-call rota appeared compliant with the EWTD and no  issues were raised.

Issues had been raised at the ARCPs this year regarding patient safety. The department have put M&M meetings in place to help address some of this problem. There also is an on-going change of consultants within the department which is improving the safety culture.

There were no safety issues raised by ITU, Midwifery or theatre staff.

Department / Programme / Specialty

Area of development

 

The CT2s felt that the induction could have been more explicit around the behaviour expected of trainees. For example there is an expectation that trainees should be in before their consultant to see preoperative patients.

The CT2s suggested that photographs of key staff, for example, the Clinical Director and College Tutor could be displayed in the department and this would have helped them identify consultants when first in post.

Communication and team building between CT and middle grades needs to be developed.

Continued development of M&M and safety culture.

Supervision – clinical and educational (inc. career guidance, feedback)

There has been a recent change in Educational Supervisors (ES) There had been complaints previously about unnamed individuals at ARCPs. There were no such complaints at this visit. The consensus amongst the trainees is that the nominated ESs are in these positions because they are engaged with the responsibilities required to be an ES.   All trainees feel they are well supported by their ES and other consultant colleagues.  Trainees reported being able to meet with their ES early in post.  No issues with ES were raised although there is variable engagement with WPBA’s. Some trainers are keen to sign off and others are not. It is difficult to get the required numbers completed and they are usually signed off retrospectively.

Educational Supervisors felt that the Peninsula Postgraduate Medical Education (PPME) courses provided adequate training. The department continues to have a1:1 ratio of ES: trainee.  The trust remunerates ESs at 0.25pa’s per trainee. ES would appreciate a road map of expectations for training. Obtaining professional / study leave from the trust for an educational related activity was not a problem.

Clinical supervision is generally regarded to be good with all consultants and non-consultants engaging in teaching. There is a developing culture that encourages trainees to seek out and be called to teaching opportunities distant to where they are rota’d in order to maximise the use of training experiences. A named supervising consultant of the day was described who could co-ordinate this.  Some trainees described consultants leaving their lists early expecting the trainees to finish the lists.

No trainees described feeling vulnerable in any clinical situation. Trainees spend the first 2 months doing only supervised day time work before they are integrated into the on call rotas. CT1s mentioned that they didn’t get much feedback from the department when they were moved onto the on-call rota. They would like to know when and how it had been considered they were ready for these duties.

The trainees were aware that they could seek career guidance from their ES/CT as well as the through PPME.

All trainees knew about the mentoring service offered through the Trust/department.  No trainees reported using this service.

Some CT2s felt they had too much supervision and would have like to do some solo lists.

Trainers have tried to refrain from using locums for supervision which has been difficult during the past year due to the number of locums within the department.

Trainers felt that the advantages of a small department meant  they could provide close training  relationships, more regular interaction with specific trainees, targeted and tailored training and great opportunities, specifically mentioning less competition between trainees, transfer training and simulation training.

Communication between the trust Anaesthetic middle grades and CTs is important so that a team approach can be developed, particularly for out of hours working. The suitability of these Trusts appointees to supervise trainees was expressed and increasing their involvement in trainees supervision must be carefully monitored.

Department / Programme / Specialty

Area of development

 

Develop a feedback process for when trainees move onto the on call rota, identifying their strengths and areas to improve.

Encourage better engagement in WPBA’s.

Advertise the confidential mentoring service offered through Peninsula Postgraduate Medical Education.

The department lacks a room in which to hold a private meeting. This would help address a number of confidentiality concerns raised through various sources of trainee feedback.

CT2 Trainees need to have some clinical practice without direct clinical supervision. This is important so that they are well prepared for ST posts.

The School wants a minimum ratio of 2 trainees:1 ES for quality assurance.

Training environment (inc. access to educational resources

The training opportunities are adequate but considerably less than other teaching centres in the region. This makes modular training difficult to deliver, although with motivation a trainee can be exposed to the required CT competencies over the 2 year placement.   There appears to have been considerable improvement in the culture regarding education and training support for trainees, eg M&M meetings, lunchtime meetings, ad hoc teaching – VIVA practice and clinical teaching.

The department was cramped and appeared short of computers and space for the number of staff. There were books available (general and exam specific) and simulation teaching was thought to be good and useful. There is anaesthetic training material available on the trust intranet.

Middle-Grade doctors should be covering more ICU work, giving CT’s more opportunity to gain experience in theatre.

ITU nurses, midwives and ODP’s reported a broadly supportive consultant group who were usually available when required. They commented that trainees were inexperienced and had varying competencies/ capabilities. They noted that the service required senior experienced nursing input and if more work was performed by unsupervised trainees this could become a problem. Currently they did not feel that there were patient safety issues.

Department / Programme / Specialty

Area of development

 

The department / trust needs to develop more office space, better IT resources and WiFi availability throughout the critical care environment.

Further work is needed to optimise the clinical opportunities made available to trainees so that they are on parity to other CTs in the region at the end of the 2 year rotation.

Work load

Trainees are supernumerary for 2 full months and then not being placed on night time on-call rotas until they have had at least 3 months experience.

They then take part in a rolling rota. Almost all lists are supervised throughout their whole time in NDDH. There is a modular approach to training which includes 3 months on ITU. The number of cases undertaken at NDDH means that modular training is difficult to deliver: Trainees are therefore encouraged to look for ad hoc training outside of modules to improve exposure. There did not appear to be any issues regarding the number of hours worked per week.

The trainees feel that there is too much ICM work. Unfortunately their on-call consists mainly of ITU work and obstetric epidurals (which is not what they are taught during the initial training for the IAC).

They suggested that it would help them if they received 1 week on ITU prior to going on call to help them feel more secure in this new environment. The 5-9 ITU shift reduces their availability for emergency anaesthesia experience. It also adversely skews the amount of time spent in ITU as a proportion of the time spent in anaesthesia. The use of middle grades in ITU appears to have helped this by both reducing the hours in ITU and enhancing the team and subsequent training on call. The Department is trying to get middle grades to cover 5-8 shift to allow CTs time to go to theatre and gain emergency anaesthesia experience. 

The trainees would also like less supervision with more solo lists for the CT2 trainees. It was felt by trainees that they would benefit from undertaking solo lists as this would increase their confidence and help to prepare them for ST jobs.

 

 

 

Department / Programme / Specialty

Area of development

 

Consider further changing the medical cover of the ICM 5 – 9pm shift.

Adequate experience / achievement of curriculum competencies

A good balance of learning on the job and teaching was described by the CT1 trainees. They felt they had started to gain a breadth of experience.

Early experience of epidurals at CT1 level was described.  The CT2 trainees said they had completed 5-10 observed epidurals before doing this procedure unsupervised. They felt this was only just sufficient experience to be consenting for and delivering this service.

The CT2s said they do too much Intensive Care when on-call which meant they miss theatre experience.  Encouraging middle grades to cover the early evening shift (5-8) would allow the CT2s to get to theatre.

The CT2s would value experience of straight forward lists with less supervision and, although it is acknowledged that lists can be hard to predict, this is something that the department is looking at. 

The department is keen to establish more flexibility for trainees to ensure exposure to a wide breadth of cases. For example, allowing trainees to concurrently attend a number of theatres.

The availability of paediatric and ENT cases is limited.

There is an acute pain service and trainees can go on ward rounds with the acute pain nurses. It was not clear if there was consultant input into the acute pain ward rounds. There has not been a robust chronic pain service, but a new lead has been appointed and should improve opportunities. Pain training was limited.

Vascular services have been centralised away from NDDH.

Trainees did not report any problems having work place based assessments signed off however they did comment that they chose assessors carefully to avoid problems.

Trainers described 1600 deliveries; 10k operations, 80% of which are day cases.  6 beds, 4 x level 3 – plans to expand.

North Devon Hospital is small which means that exposure to clinical experience is less easily predicted. The particular areas that appear to cause difficulty are NCEPOD work, paediatrics and some obstetrics (particularly LSCS). The modular approach to training appears to help ensure that the curriculum is covered but it is important that trainees and trainers keep an eye on where gaps appear due to variability in case load presentation. They appear to be well supported with undertaking WPBAs, and there is a very healthy attitude towards maximising training opportunities. The smaller amount of obstetric and emergency experience does leave trainees feeling slightly underprepared for taking on ST posts.

Department / Programme / Specialty

Area of development

Teaching – local, regional and study leave

CT1 Trainees attended the regional induction and e-portfolio training. NDDH trainees are attending the 7 ‘super Thursdays’ that cover basic sciences and exam prep courses for many parts of the FRCA. In addition Taunton and NDH try to combine to deliver 4 days primary teaching each. Of note, the NDDH tutorials all have the subject TBA for 2015. Taunton’s subjects are already advertised.

The department delivers local novice teaching towards the initial anaesthetic competencies, which includes excellent simulation training. CT1’s were very satisfied by this. This had ‘fizzled’ out recently. The programme provided was very simulation centric compared to other LEP novice training programmes.Morbidity and Mortality (M&M) meetings have started 2 months ago and lunchtime teaching. The monthly M&M meetings were recognised as an area of good practice.  They are advertised a week in advance and theatres are held back until 9.30am to enable attendance.  Minutes are produced for those unable to attend.

There were comments regarding the lack of on-going formal teaching for CT2 trainees. Senior CTs outside of the Super Thursdays or combined teaching days get no formal teaching. The CT2 reported having no formal teaching in the last 4 months. CT2s have been encouraged to take part in teaching novices with a variable response. Exam preparation teaching, OSCE and VIVA training was limited or absent for the CT2s.

Teaching in theatre was described by the CT1s as proactive.

There appear to be no issues surrounding getting study leave.

The visiting panel did not hear of any instances where study leave had been turned down.

Whilst the visit did not go into specific detail, trainees reported that simulation training was good.

The CT1s expressed some concerns around exam preparation and said they would value viva practice.

Formal ITU teaching or journal club was not organised

Department / Programme / Specialty

Area of development

CT  anaesthesia

CT 2 teaching needs to be expanded and focussed on exam preparation.

Review teaching programme for novice teaching and combined  NDDH/ Taunton teaching programmes to ensure that curriculum covered.

Bullying and harassment

When asked about undermining the CT1 trainees described one or two isolated incidents.

One trainee has left the department expressing that she had felt undermined, unsupported and bullied. Discussion with  a variety of trainers revealed that they had received considerably more personnel support, mentoring and supervision than other trainees: It was felt that this trainee might not have been suitable for a career in anaesthesia and  had many issues making their case unique and not reflective of the department’s approach to trainees.

Last year, 3 weeks after they had arrived, the trainees had been told ‘ they were being watched’ by a consultant at a teaching session. They felt this was threatening and unsupportive behaviour.

The CT2 trainees described feeling slightly overwhelmed and unwelcome when starting work in the department.  They said this might have improved from August 2014.  The CT2s felt their confidence had been knocked at the start of the post but they had not felt undermined. This had been compounded by a lack of clarity of expectations explained to them during induction.

There were no such complaints from the CT1s. It appears that induction has improved (the SOP document looks very good), and a change in staffing has produced a more positive environment. These improvements are on-going.

There were also comments regarding admin support. It appears that office staff have been under considerable strain and changes in management arrangements recently have improved the situation enormously.

A number of trainees acknowledged that the department was small and they would perhaps find it difficult to find someone or somewhere to talk to in confidence, particularly when new in post.  Some of the CT1s felt that the new Department Lead would be a trusted point of contact.

The visiting team found no evidence of a culture of undermining and harassment.

 

Department / Programme / Specialty

Area of development

 

Advertise confidential point of contact for trainees experiencing concerns / difficulties

Additional comments / feedback

The visit had been planned for and organised very well. The Panel were able to see lots of people, including most of the trainees. The trainers appeared a very enthusiastic team, with a very high level of attendance at this LEP review.  All trainees attended, together with a strong turnout from trainers, ITU Consultants, Nurses, ODP’s and Midwives.  This provided excellent inputs into the review, from a wide range of contributors.

NDDH is a small hospital which produces limitations on the availability of experience compared to other organisations. This does though have notable advantages for novice trainees as it allows close relationships, regular interaction, tailored targeted early training and good opportunities as there is less completion.

There has been considerable effort put in recently to improve induction, the quality of supervision and mentoring, teaching, exposure to epidurals and other ad hoc events, the use of the middle grade as trainers and as an on call team member and M&M meetings. This work appears to be on-going  with the department looking critically at the remaining problems – lack of solo lists, insufficient NCEPOD type work, too much ITU (particularly the 5-9 shift) and formal teaching in the CT2 year and admin support in the department.

Overall there appears to have been a significant change in culture over the past year or so which has resulted in the department addressing issues which have caused considerable problems in the past. They should be congratulated on their work. There appeared a real enthusiasm and passion from some key members of the department to work on developing the training components of their departmental activities.

Department / Programme / Specialty

Area of development

 

 

 

Visit Panel Chair Declaration

This completed report is a true and accurate account of the discussion that I participated in or were reported to me from this visit.

The key recommendations have been identified within this report have been identified with good faith.

I can confirm that any areas of significant concern and that have a direct impact upon patient safety has been brought to the attention of the relevant Director of Medical Education (or equivalent), responsible Medical Director and Executive Lead for Quality at Health Education South West Peninsula Postgraduate Medical Education.

Chair name:

 

Dr James Pittman

Chair educational role:

 

Head of School

Date of signature:

 

 

 

 

 

 

 

 

Health Education South West Peninsula Postgraduate Medical Education Declaration

I as signatory on behalf of Health Education South West, Peninsula Postgraduate Medical Education can confirm that the information and associated recommendations provided via this report has been reviewed and deemed appropriate for the purpose as stated.

That recommendations contained within this report have been documented as part of the quality management processes of Health Education South West Peninsula Postgraduate Medical Education and where appropriate will be reported to the General Medical Council (GMC) as required.

Name:

 

Dr Martin Davis

HESWPPME educational role:

 

Associate Dean for Quality

Date of signature: