On-call Provision in a DGH

We are a general DGH with a 12 bed combined Critical Care unit and a well-established NIV service run by the respiratory physio team during daytime hours.

Our overnight and weekend on-call service includes all rotational staff (9 Band 5’s, 7 Band 6’s), the respiratory team of 8 mostly part-time staff and the inpatient static Band 6 and 7 staff, another 6. So we have a total of approximately 30 staff available.

As we are based in Cornwall we frequently run with vacancies. Despite the fact that Cornwall is a lovely place to live (and to surf!) this doesn’t always attract people to our jobs.

With sickness and maternity leave, which is a fairly frequent occurrence, we are often down to 20.

Until recently, our rota included the outpatient staff for overnight duties, but this changed with the introduction of a seven day contract. In the near future our weekend on-call service will cease in its current form and respiratory work will be covered by the respiratory team and rotational staff .

The present weekend service has run well for many years. We provide training annually with monthly update sessions which are open to all staff and we offer an open-door policy to all on-call staff to spend time with us on the wards for practical skill updates. We are good at maintaining competence and test this with the practical assessment and theoretical questioning at training sessions, but maintaining confidence is always a challenge for some staff; hence the open-door to practical ward-based sessions.

We are fortunate in that we do not have complex interventions or complex surgery patients to include on our training schedule. We still have several Bird machines, and cough assist machines to include with standard physiotherapy interventions for ventilated and self-ventilating patients.

Positives

Call outs are not frequent. Call-outs run at a rate of approximately five per week (unless we have unwell CF or paediatric patients). It is unusual to be called more than once or twice in a night.

A small team means it is easy to keep a track of the skills and weaknesses of all staff and therefore direct training and support.

The most senior respiratory staff offer a back-up buddy system for any issue which arises on-call where a staff member feels they are faced with a situation out of their normal scope of practice. This might include very rare calls to neonatal unit, a complex paediatric or critical care case which we would not have been able to cover in standard on-call training. This has never been used but staff feel reassured knowing they can always contact one of two people who will be happy to help.

New staff have formal training and several ward-based sessions whilst completing the competency matrix and self-evaluation questionnaire. When they start on the rota they are buddied until they have been called out at least once on a duty, but they are encouraged to call once of respiratory seniors if they ever have a problem.

Negatives

Infrequent call-outs can mean it is tricky to maintain confidence.

A small rota means we have to include staff who do not routinely see respiratory patients in their daytime role.

At times we have dropped to 16 on the rota.

Compensatory Rest

As part of the up-coming move to seven-day service we negotiated a compensatory rest agreement for overnight duty. Our stewards were excellent in presenting options and negotiating with management. The compensatory rest is based upon the time at which you are called and the time at which you return to your home. So if you are called and are back home before midnight, and if you are called after 6am, you do not qualify for compensatory rest. In between these times, the amount of rest depends on whether you return home before or after 2am. The rotational staff on outpatient rotations book admin time the morning after an on-call duty to allow for compensatory rest which means the rota has to be done well in advance or they swap their duties to ensure their on-call and admin fall on the same day each time. So far this has worked very well.

Challenges for the Future

The limited seven day service - there isn’t funding for an equal service across seven days, so the change is that our current emergency respiratory weekend service will be provided as part of normal hours, with TOIL in the week, not overtime as at present. In times of sickness or vacancy this may be very difficult to staff, but as we are the only service in our Trust who operate a planned weekend service paid with overtime, we are not able to continue now that on-call/weekend services are being harmonised.

Maintaining overnight on-call competence for some staff in the new system may be difficult as they will no longer be doing weekend duties.

Sian Goddard, Clinical Specialist Physiotherapist in Respiratory Care

Sian has been co-opted to the ACPRC committee to drive forward our on-call project.

oncallproject@acprc.org.uk