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North Tyneside General General Hosp[ital,
With reference to the article 'The impact of 24hr consultant shop
floor presence on emergency department performance: a natural experiment',
by Christmas, Johnson and Locker, EMJ May 2013 Volume 30, Issue 5, pages
Some initial comments arise from reading...
Some initial comments arise from reading this article. Whilst, there
is no significant difference in the mean number of patients, in the
department, at the start of the night shift (table 1), there are slightly
less on the consultant nights.
The medical staffing (table 3) would appear to be slightly better on the
consultant nights (for SHO, middle grade and other consultant.)
Whilst using an age and presentation by ambulance, as surrogate markers of
case mix, one wonders why the usual triage categories (P1-4) are not used.
The figures in Table 2 are percentages for each category. One might
surmise that on the consultant nights, which are predominantly Friday,
Saturday, Sunday (69% versus 38% for middle grade nights) that the case
mix would be very different to weekdays, in that there would be more minor
cases in the age band 16-65, who may arrive by ambulance, but end up being
fairly minor cases. Whilst, the percentages in each category may be very
similar, this may not be reflected in the complexity of the actual cases.
Thus, the median waiting time and length of stay may be less for the
consultant nights, this may be due to a greater proportion of cases being
of less severity or taking less time to sort out. The mean number of cases
presenting per hour is roughly one patient per 2 hours more for the
Equally, one could argue that the busy weekend nights (although not that
much busier by the data provided), with more intoxicated patients, who
take longer to manage, has been more efficiently managed on the consultant
nights. However, it is difficult to tease out the true complexity of
cases, to say with certainty that this is so. One might empirically say
(and hope) that having consultants around makes the department run more
efficiently, by offering timely advice and active management (perhaps just
by having the 'boss' around), but the figures show that both groups met
the 4 hour target and had no difference, in the surrogate marker of safe
discharge, namely, proportion of patients returning within 7 days.
One wonders why the authors have used median waiting and length of stay
times (one assumes the spread is the median times for all nights), which
again takes no reference to the case mix and how many cases were very
minor and took little time to see and more complex cases which take longer
to see. These factors will not be obvious when a median value is used.
The proportion of cases admitted on consultant nights is slightly less
compared to middle grade nights - could this be due to more minor cases
presenting on weekend nights, who do not require admitting and thus
accounting for a smaller percentage of cases, overall, requiring
Either way, a 3% reduction in admissions of say 30 patients per night,
equates to 1 patient per night.
This article states that there is no significant difference in any of the
outcome measures in Table 5, comparing the daytime, when a consultant is
not available to be around, as they are doing the nightshift, versus when
they are available and the middle grade is doing the night shift ie. the
additional consultant makes no difference, during the day. This is an
intentionally provocative statement, as obviously, as has already been
mentioned in the article, there are other consultant duties that are not
At first sight it looks as though having consultants working nights
decreases the median waiting and length of stay times and reduces the
proportion of patients admitted. However, I would propose that it is not
as straight forward as this. We are not comparing like for like - compare
consultants versus middle grades nights, purely on weekends and purely
The article states that some of the reduction in process times is due to
consultants seeing patients more quickly. The College recommendations are
that consultants will work in a supervisory role overnight, or are they to
be turned in to F2's for the rest of their careers?
These comments are deliberately provocative, but do show that figures can
be used to show what you like and that they do not tell the whole story.
Managers may read articles such as this and see headline of 'consultants
reduce waiting times and reduce admissions' - well, they reduce the median
wait on weekend nights in a group of patients that possibly includes more
minor cases and in either case, all of them are seen within 4 hours and if
your department admits 30 cases overnight, then you will reduce the
admissions by 1 per night and your marker of safe discharge is no