Hospital Dr News

More on site consultants needed for acutely ill

A national enquiry into cardiac arrests highlights the need for consultant physicians to be available seven days a week to assess acutely ill patients, says the Royal College of Physicians.

A third of in-hospital cardiac arrests and subsequent attempts to resuscitate could have been prevented finds the review by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).

Patient assessment on admission was deficient in 47% of cases, and there were warning signs that the patient was deteriorating and might arrest in 75% of cases.

However, the warning signs were not recognised in 35% of those patients, not acted on in 56% and not communicated to senior doctors in 55% of cases.

NCEPOD advisors found a lack of input from senior clinicians in the 48-hours prior to cardiac arrest.

The report, Time to Intervene, calls for better assessment of patients on hospital admission and improvements in recognition and response to patient deterioration and decision-making around what care is likely to benefit acutely unwell patients, including do not attempt cardiopulmonary resuscitation decisions (DNACPR).

The report found that even when a DNACPR decision had been made it was not always followed and 52 patients underwent CPR despite their explicit DNACPR decision.

Dr Mark Temple, the RCP’s acute medicine fellow, said the report flagged the importance of early consultant review of patients admitted acutely to hospital.

Quality of patient care in the first 48 hours in hospital was a critical determinant of clinical outcomes. Consultants should be involved in decisions to escalate treatment or transfer care to the intensive care unit for those patients who fail to respond to initial treatment or deteriorate.

The RCP recommends that consultant physicians should be available on-site for at least 12 hours a day, 7 days a week in order to improve the care of acutely ill patients.

Temple added: “Decisions about the appropriateness of cardiopulmonary resuscitation in the event of cardiac arrest are complex and consultants should be involved in these decisions early in a patient’s acute illness. There is also a need for the healthcare professions and the public to develop a shared understanding of the limitations of CPR and the very low success rate of this intervention in patients where cardiac arrest occurs secondary to non-cardiac disease.”

Report author and NCEPOD lead clinical co-ordinator, Dr George Findlay, said the recognition of acute illness, response to it and escalation of concerns to consultants when patients were deteriorating was not happening consistently across hospitals.

“Senior doctors must be involved in the care planning process for acutely ill patients at an earlier stage, and support junior doctors to recognise the warning signs when a patient is deteriorating. The lack of senior input fails patients by both missing the opportunity to halt deterioration and also by failing to question if CPR will actually improve outcome,” he said.

In July, the RCP will launch a National Early Warning Score (NEWS), which will alert doctors and nurses when a patient is deteriorating and trigger a consistent approach to the escalation of their care, including the involvement of senior doctors.

NCEPOD’s recommendations include:

1. CPR status must be considered and recorded for all acute admissions.

2. When patients continue to deteriorate prior to consultant review there should be escalation of care to a more senior doctor.

3. Each hospital must have a plan for the management of the patient’s airway during cardiac arrest.

4. Each hospital should audit all CPR attempts and assess what proportion should have had a DNACPR decision in place prior to arrest.

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4 Responses to “More on site consultants needed for acutely ill”

  1. Laura says:

    It is really time to adapt the title: The “Consultant” was an INDEPENDENT practitioner of his7her craft and the leader of HIS/HER FIRM. There is no such thing any more – what is called “Consultant” today has nothing whatsoever to do with anything deserving that title. There are no more true consultant posts – and to achieve that was the real reason why all these reforms of training have been undertaken. They produce a big pool of specialist doctors who do as they are told. THAT is what the gvmt wanted all along, nothing else. To call all these doctors on the shop floor “Consultants” is plain ridiculous.

  2. Rob says:

    In order to get the best candidates for a post you have to make the job attractive. Do the learned members of RCP really think that anybody half way decent is going to want to do a job as a hospital consultant that fulfills exactly the credentials of what a senior SHO used to do and spend most of their working life doing this with no identifiable team and zero continuity of care and get paid less than a GP.

  3. Supersub says:

    I’m with Rob on this.
    Association is not the same as causation – there are too many variables to blame weekend deaths on consultant working patterns alone. A randomised trial is needed. If it shows having a consultant there 7 days a week resolves the mortality difference – great – but if not, forget it.

  4. lizzieK says:

    Medicine is complex and outcomes are multifactorial. the RCP seems to be saying that getting consultants to stay in the hospital for longer is the answer to every problem. We knew when the new training came in, when the EWTD was adopted, when maternity leave and PhD training was counted towards a CCST/CCT this would have an impact on the experience of trainees..are we surprised? making consultants do it all may be a quick fix but what happens when they retire? and what about trainees..what is left that will convince them to complete their training? Final thought. there was an article in the BMJ a few years back from Drs Empey and Peskett that looked at older consultants. Basically it said there is good evidence they become less effective as they rely on more on experience and not new knowlege.

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