Covering ENT out of hours: how confident are senior house officers?

Undergraduate perceptions on the educational value of a novel ENT e-Learning platform

ENT is a consistently under-represented specialty in medical school curricula. With social distancing measures limiting face-to-face (FtF) teaching and clinical opportunities, we created an e-Learning platform to consolidate and improve knowledge on common ENT emergencies. Following invitation to medical students undergoing their rotation in ENT at University Hospital Wales (UHW) Cardiff, five focus groups were shown an e-Learning module and interviewed between June and July 2021. 13 medical students participated in total (9 female, 4 male, median age 22 years). These structured interviews were recorded and transcribed. Transcripts were analysed using the qualitative data analysis software NVivo (QSR International, UK). The modules were found to be concise, clinically relevant and beneficial to student confidence in recognising and managing ENT emergencies. While e-Learning will likely never replace face-to-face learning, it was perceived to be a beneficial resource both academically and practically- especially in the context of limited clinical opportunities.

Appropriate Medical Staffing Improves Patient Safety, Training and Doctor Wellbeing

Background Cross-covering of medical and surgical specialities out-of-hours is a problem in many hospitals, leaving trainee doctors responsible out-of-hours for patients they have never met, in specialities where they do not normally work. This has implications for patient safety and doctor wellbeing. In our Trust, a historical decision resulted in trainee doctors in Trauma & Orthopaedics and Ear Nose and Throat Surgery being reallocated out-of-hours to cross-cover medical inpatients. This left one doctor cross-covering all surgical specialities, including General Surgery, Urology, Vascular, Ear, Nose and Throat surgery (ENT), Trauma & Orthopaedics (T&O) and Spinal Surgery. As the out-of-hours workload increased over time, this impacted negatively on patient safety and doctor wellbeing to a point where it became unsustainable. Methods Evidence of safety concerns relating to surgical night shifts was gathered from Exception Reporting data and anecdotally from the Postgraduate Doctor Forum. Once the scale of this problem was accepted by the hospital board, following the successful presentation of two Business Cases, 17 additional doctors were recruited. This recruitment reduced the cross-covering of specialities out-of-hours and enable adequate staffing throughout all departments. Qualitative evidence was gathered by surveying affected doctors before and after the change in order to assess its impact on doctor wellbeing, training and perceived patient safety. Quantitative analysis of Exception Reports and Immediate Safety Concerns was also performed. Results The survey results following the change were overwhelmingly positive, demonstrating a significant improvement in workload, rest breaks and quality of care for patients. Foundation doctors reported higher levels of confidence and enhanced training due to more consistent supervision. Job satisfaction improved, with 81% of surgical senior house officers reporting they would recommend their job, compared with 42% previously. Trends in out-of-hours Exception Reporting and patient safety concerns were analysed to show a moderate improvement following the intervention. Conclusion With the ever-increasing volume and complexity of patients presenting to global healthcare systems, it is key that staffing levels are safe and adequate in order to maintain patient safety and doctor wellbeing. This project has demonstrated how historic short-term fixes such as redeploying trainee doctors out of their home speciality and implementing cross-cover of multiple specialities can have detrimental long-term effects. Our preliminary data revealed multiple issues related to patient safety, junior doctor workload and lack of training opportunities. By using this data, and enlisting the help of multiple valued senior stakeholders, an acceptable Business Plan was approved by the Trust with a view to reversing these issues. The recruitment of additional Trust Grade doctors to create a third tier of the surgical out-of-hours cover has been instrumental in improving conditions within our Trust and has shown that adequate workforce planning is achievable when supported by robust evidence. This project could be used as a guide for other units seeking to make similar improvements.

Defining performance levels in undergraduate otolaryngology education

OBJECTIVES

This study seeks the opinions of qualified doctors on what they feel medical students should learn about otolaryngology. It aims to identify both the content deemed relevant and the performance levels for medical students in otolaryngology.

METHODS

A national survey developed from a content analysis of undergraduate otolaryngology curricula from the UK was undertaken, accompanied by a review of the literature and input from an expert group. Data were collected from a wide range of doctors.

RESULTS

Participants felt that graduating students should be able to: recognise, assess and initiate management for common and life-threatening acute conditions; take an appropriate patient history; and perform an appropriate examination for the majority of otolaryngology clinical conditions but manage only a select few.

CONCLUSION

This study reports performance levels for otolaryngology topics at an undergraduate level. Participating doctors felt that a higher level of performance should be expected of students treating life-threatening, acute and common otolaryngology conditions.

The provision of ENT teaching in the undergraduate medical curriculum: a review and recommendations

OBJECTIVE

The existing provision of ENT teaching in the undergraduate curriculum is deemed inadequate by medical students, general practitioners and ENT surgeons alike. This study aims to explore the perceptions of a variety of stakeholders on how undergraduate ENT provision can be optimised.

METHODS

This study involved semi-structured interviews with seven participants (two medical students, two general practitioners, two ENT surgeons and a curriculum developer). Inductive thematic analysis was used to identify key themes that emerged from the interviews.

RESULTS

The four emergent themes were evaluation of current ENT provision, barriers to learning and teaching, alternate means of delivery of ENT education, and professional identity development. A number of barriers to learning and teaching in the clinical environment were identified including student-related, teacher-related and environmental factors.

CONCLUSION

The existing ENT provision should be re-considered to help students achieve a basic level of competence in managing common ENT conditions. This can be achieved by ENT teaching in additional contexts including general practice, e-learning and simulation workshops.

A novel ENT iBook: what do junior doctors think?

Exposure to the specialty of Otolaryngology is limited. It may be consolidated by the use of an iBook as a self-study tool. The purpose of this study was to ascertain the perceptions of junior doctors on the clinical relevance of this novel educational resource. Three focus groups were formed each consisting of five junior doctors (eight female: seven male, median age 27 years). The iBook was found to be clinically relevant to the work of junior doctors, have a clear layout, with adequate interactivity and a good range of integrated multimedia elements.

Night emergency cover for ENT in England: a national survey

Objectives:

To evaluate the quality of out-of-hours ENT on-call cover by junior doctors, in view of the European Working Time Directive and the recent changes in the National Health Service workforce due to the ‘Modernising Medical Careers’ initiative, in England.

Methods:

We performed a national survey of first-on-call doctors for ENT, using a telephone questionnaire. Hospital contact details were sourced from the National Health Service website. The inclusion criterion was hospitals providing acute ENT facilities overnight in England.

Results:

One hundred and nineteen hospitals were contacted; 91 were eligible, and 83 interviews were conducted. The grade of the first-on-call ENT doctor ranged from foundation year two (19 per cent) to registrar level or above (13 per cent). Forty-nine respondents (68 per cent) reported having no previous ENT experience. Fifty-three respondents (74 per cent) covered more than one speciality at night, with seven (10 per cent) covering four or more specialities. The second-on-call doctor was non-resident in 63 cases (88 per cent). Thirty respondents (42 per cent) stated that they did not feel comfortable managing common ENT emergencies as the first doctor on call. Otorhinolaryngology induction courses were offered in 37 of the respondents’ hospitals (51 per cent), these courses were of varying duration.

Conclusion:

Night-time ENT care is often provided by junior doctors with little experience of the speciality, who are often also responsible for covering multiple specialities. Many reported not feeling comfortable managing common ENT emergencies. Structured induction programmes would help to provide basic knowledge and should be mandatory for all doctors covering ENT.

Patient safety in otolaryngology: a descriptive review

Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published. The report extrapolated that in the USA approximately 50,000 to 100,000 patients may die each year as a result of medical errors. Traditionally otolaryngology has always been regarded as a "safe specialty". A study in the USA in 2004 inferred that there may be 2600 cases of major morbidity and 165 deaths within the specialty. MEDLINE via PubMed interface was searched for English language articles published between 2000 and 2012. Each combined two or three of the keywords noted earlier. Limitations are related to several generic topics within patient safety in otolaryngology. Other areas covered have been current relevant topics due to recent interest or new advances in technology. There has been a heightened awareness within the healthcare community of patient safety; it has become a major priority. Focus has shifted from apportioning blame to prevention of the errors and implementation of patient safety mechanisms in healthcare delivery. Type of Errors can be divided into errors due to action and errors due to knowledge or planning. In healthcare there are several factors that may influence adverse events and patient safety. Although technology may improve patient safety, it also introduces new sources of error. The ability to work with people allows for the increase in safety netting. Team working has been shown to have a beneficial effect on patient safety. Any field of work involving human decision-making will always have a risk of error. Within Otolaryngology, although patient safety has evolved along similar themes as other surgical specialties; there are several specific high-risk areas. Medical error is a common problem and its human cost is of immense importance. Steps to reduce such errors require the identification of high-risk practice within a complex healthcare system. The commitment to patient safety and quality improvement in medicine depend on personal responsibility and professional accountability.

In the face of increasing subspecialisation, how does the specialty ensure that the management of ENT emergencies is timely, appropriate and safe?

Background:

The field of ENT surgery is one of the most varied specialties, with numerous subspecialties and continuing divergence. With this evolution there comes, however, a risk that specialists become de-skilled in certain areas. In the case of ENT emergencies, this can be particularly dangerous.

Methods:

Current guidance from relevant UK professional membership bodies regarding emergency surgery provision was inspected and a literature search was performed to identify studies relating to management of ENT emergencies in the context of increasing subspecialisation.

Results and conclusion:

The specialty currently has provisions in place to ensure timely, appropriate and safe management of emergencies, in the form of guidelines and emergency clinics; however, there is scope for improvement of the system.

Epistaxis management: current understanding amongst junior doctors

Background:

Epistaxis is a common and potentially life-threatening emergency. This survey assesses understanding and confidence in epistaxis management amongst current junior doctors.

Method:

A cross-sectional study was conducted of foundation year one and two doctors based at three National Health Service trusts within a single region of the UK, assessing basic understanding and procedural confidence.

Results:

A total of 111 foundation doctors completed this survey. The average duration of undergraduate exposure to otolaryngology was 8.1 days. Forty-one per cent of respondents stated that they would apply pressure to the nasal bones to control epistaxis. Seventy-five per cent lacked confidence in their ability to manage epistaxis. Those with two weeks or more of undergraduate exposure to otolaryngology were more confident than those with one week or less of exposure (p < 0.0001).

Conclusion:

Junior doctors lack understanding and confidence in epistaxis management, with patient safety implications. Confidence is associated with the duration of undergraduate exposure to otolaryngology. A minimum emergency safe competency should be a priority during foundation training if not achieved in UK medical schools.

The Impact of the European Working Time Regulations and Modernising Medical Careers on Out-of-hours ENT Cover

The implementation of the European Working Time Regulations (EWTR), coupled with the ongoing impact of Modernising Medical Careers (MMC), has necessitated a significant redevelopment of out-of-hours cover for surgical specialties in the UK. A review of the literature related to the provision of out-of-hours ENT cover gives an insight into the impact of these changes on a comparatively small surgical specialty. A 2008 survey revealed that three-quarters of junior doctors providing ENT out-of-hours care were crosscovering specialties other than ENT – a figure up from just over half of junior doctors in 2005, prior to stricter EWTR rules. Of all 'first-on-call' doctors for ENT, only 19–32% have prior ENT experience. Consequently, ENT services are provided frequently by inexperienced, non-enT doctors covering multiple other specialties, often as part of a 'hospital-at-night' team.

Out-of-hours cover in oral and maxillofacial surgery

The European Working Time Directive (EWTD) has required all departments to re think staffing arrangements to provide out-of-hours ser vices. Large departments with man y junior doctors can continue to have oral and maxillofacial surgery (OMFS) SHOs covering the out-of-hours ser vice without exceeding the constraints of EWTD. For smaller departments the choice has been either to close the on-call service and centralise it in a larger department or to have a specialty cross-cover arrangement. The problems of cross-cover might be more apparent in OMFS than in other hospital specialties due to other medical staff possessing a negligible knowledge of dental pathology.

Front-line epistaxis management: let's not forget the basics

OBJECTIVE

We postulated that epistaxis patients frequently have their nose packed in the accident and emergency department without any reasonable prior attempt at nasal assessment and nasal cautery.

DESIGN

Telephone survey of 104 accident and emergency departments.

RESULTS

A 100 per cent response rate was achieved. In all but one of the departments surveyed, first line management was carried out by accident and emergency doctors. Seventy-four per cent of accident and emergency doctors perform nasal cautery as first line management. Within accident and emergency departments, the availability and usage of head illumination, nasal speculums, topical anaesthesia and suction was grossly suboptimal. Only one-sixth of the accident and emergency doctors surveyed had received training in the management of epistaxis, whilst 81 per cent of accident and emergency departments would admit nasally packed patients under the ENT team.

CONCLUSION

Despite the majority of accident and emergency doctors claiming to attempt nasal cautery before packing, this is unlikely to be effective if performed without the correct equipment. Better training and equipment need to be provided to accident and emergency doctors in order to optimise the management of epistaxis patients. This could potentially reduce inappropriate admissions.