Discussion

Wrexham Maelor is a district general hospital, which receives unrestricted emergencies. The ED consultants have engaged in service delivery since 1996. In a clear departure from the traditional supervisory model of consultant activity of that time, we embarked on partial shift (days, evenings and weekends) working since 2003 with a three consultant team. The senior-most consultant (retired in 2008) was not rostered for any unsocial hours work.

The benefits of consultant delivered service do apply equally round the clock. Our current workforce has precluded this 24/7 working. The qualitative impact (safer procedures, better communication and risk reduction) of EM consultant working is perhaps of more value to patients and employing trusts, but is difficult to prove from a retrospective study. This paper provides some evidence of the quantifiable benefits.

As our workload and the clinical needs of our patients have increased, we have shifted the bias towards a senior delivered service (table 1) and increased its efficiency by reduced admissions, clinic returns, re-attender rates and ED LOS (figures 1 and 4). Today, the senior doctors (consultants and middle grades) outnumber the juniors (13 vs eight), in contrast to the 2007 survey1 where most UK departments were junior heavy and perhaps still are. Both grades of seniors carry a workload higher than suggested by the College of Emergency Medicine (1500 patients/year for a consultant and 2000/year for middle grades) for a medium sized ED.3 This is in addition to the usual duties of supervision, vetting decisions, teaching/assessing and administration. The consultants' own workload and admission rates vary (figures 2 and 3), but still result in an overall low admission rate, which has steadily fallen over the last 7 years (table 1). We believe this is due to the overall impact of their presence at extended hours and superior decision making rather than individual workload. In this context, triangulation with the other two North Wales ED provides useful controls (table 2) to show significantly lower admission rates at Wrexham ED (p<0.001). Those two departments continue to depend on a junior delivered service, while their casemix, clinical dependency and patients' age distribution are very similar to Wrexham. Another efficiency benefit of consultant working maybe seen in our department's superior 4-h target performance of average 95.5% (2009), which has helped Wrexham top the Welsh performance table.5 However 4-h performance may be influenced by other variables and cannot be taken as a reliable proof of senior working, while low clinic returns might. Both our ED clinic returns and reattender rates have steadily fallen since 2005 (figure 1). There is paucity of similar data in the UK emergency medicine literature. White et al6 measured the impact of mandatory senior review on junior doctors' decision making to show an 11.9% reduction in admission, 9.4% reduction in inappropriate discharge and a 34.6% rise in outpatient referrals. Presumably, the seniors there make a positive impact on the service delivery by their presence like us. This is in contrast to the past EM consultant working model in UK, which in one study involved 30% clinical contact time (range 15–48%) and the rest distributed among teaching and administration.2 We spend our clinical sessions largely on service delivery and supervision. We restrict our administrative duties to one session. Besides, by being clinically active, we maintain our skills adequately so that we can provide appropriate clinical supervision7 and set the standards needed for patient safety.8

We embarked on night shift working in 2008 in response to many near miss events, ED backlogs and ambulance waits during night shifts manned by two SHOs after midnight. These were not helped by being on-call as consultant presence is superior to opinions. Opinions were not sought promptly or not at all despite an obvious need. This is in contrast to the model of Jaye et al9

The SHO pool was reduced to increase the middle grade tier. This decision was based on our experience, echoed by Armstrong et al,10 of decreasing junior and increasing senior workload, as well as an anticipated quality benefit. This benefit has led to recent consultant expansion. While it is logistically possible to run a 24/7 middle grade rota with eight doctors,3 we felt this was unsustainable. Because, seven of our eight middle grades are permanent SAS doctors (of excellent calibre), who would age at the same rate as us, would soon feel the physical pressures of frequent (one in eight) and long (12 h) night shifts and get disenfranchised. We felt that a shared pool of night rota, with five consultants and eight middle grades working three nights on a one in 13 frequency was the only sustainable solution. Consultant night working is now well established in Wrexham. In fact, the consultants feel that nights are quieter, provide more clinical challenge (table 3) and less distraction. We are soon due to cover four nights (with 3.5 Whole Time Equivalent new consultants); aiming for full shift working once the senior pool size reaches 20. With the current lack of middle grades, this will certainly mean consultant expansion. Consultant numbers in Wrexham, duly costed, should show good service returns for the investment. Our next study may show that savings from low hospital admission rates alone would more than pay for the additional consultants, a principle already accepted by the Betsi Cadwaladr University Health Board.

However, data from the night shifts allowed us to contrast consultant working against the middle grades and SHOs, with another SHO being constant. Our data shows that night shifts are quieter, have less minor/ambulatory patients and more with higher clinical dependency (table 3), which are mostly medical emergencies. Weekend nights (SHO only) are marginally busier but bring no greater clinical challenge.

On comparison (tables 4 and 5), it is clear that while admission rates are slightly lower than SHO nights, consultants discharge more patients without any follow-up, return fewer to ED clinic and have fewer leaving without treatment (patients did not wait). We feel that the narrow difference of admission rates (between three grades) at night shifts is due to inherently more ill patients. Despite our individual variable admission rates (figure 3), overall we certainly impact on the hospital admission rate (table 2), unlike the experiences of Goodacre et al.11 This is generic of consultant working and shop floor presence regardless of individual performances.

The efficiency of consultants' service is stark when time in the department (ED LOS) is compared for patients in each triage category (figure 4). This was shortest for the more critical patients in Priority 1, 2 and 3 (major trauma, airway compromise, sepsis, etc). In this aspect, the consultants out-performed the middle grades—presumably due to superior experience and decision making skills. While the shorter LOS for consultant shifts (in contrast to middle grade and SHO shifts) were clinically very significant in the higher triage categories, this was not statistically significant due to small sample size (table 6). For red (Priority 1) category patients, the mean ED mean LOS was 61.5 min for consultants, 104 min for middle grades and 129 min for SHO shifts. As this was not statistically significant, we did a retrospective power and sample size calculation. In order to show 5% significance (p=0.05) with 80% power to detect, the sample size needs to be 46 Priority 1 patients (actual 14) for SHO and 20 (actual four) for middle grade comparison. Overall, the consultant shifts showed a statistically significant reduction in LOS over the SHO shifts for Priority 2, 3 and 4 patients (table 6). The departmental night diary reflects this effect. A recent Australian study12 has shown similar LOS advantage of ENPs (Emergency Nurse Practitioners) and senior doctors over junior medical staff in their fast track section (ie, UK equivalent of ‘see and treat’) of their ED.

The same data from night shifts, when translated to 4 h performance targets and time bands to process patients completely (figure 5), show why a junior delivered service is unlikely to comply with timeliness of care. In the current climate of ED overcrowding and reducing inpatient beds, this model is not helpful.

This study won't show the ultimate benefits to patient care as consultant service impacts on quality of care and communication, and patient safety. The other beneficiary of consultant presence is our trainees. At night, our juniors and specialty juniors have a consultant to ratify their decisions and assist with interventions—non-invasive ventilation, sedation, and so on. The confidence from these nights has empowered our juniors to work the unsupervised nights with less trepidation.

We provide quantifiable evidence of our conviction that EM service needs to be based on consultants. The quality benefits are equally persuasive. We lament that this practice is not widespread in the UK. The College of Emergency Medicine is now actively promoting this model and lobbying for consultant expansion. We would urge our UK colleagues to engage. We assure them that it is sustainable, given enough numbers. If we practice to our professed clinical standards, we shall enhance the credibility of our specialty. We promise that life on full shift 24/7 is much better than being on call after a busy day.13