Background
Methods
Hospital A | Hospital B | |||
---|---|---|---|---|
Saturday | Sunday | Saturday | Sunday | |
Physiotherapy | 8 | 12 | 6–8 | 6–8 |
Occupational therapy | 3 | 3 | 4 | _ |
Speech pathology | 3 | 3 | _ | _ |
Dietetics | 3 | 3 | _ | _ |
Social work | 0.5 | 0.5 | _ | _ |
Allied health assistant | 4 | 4 | _ | _ |
Procedure
1. | What are the current duties/activities performed by the weekend allied health service? (Map the service on the ward). Why are they performing these roles? |
2. | What do you think are the advantages of having a weekend allied health service? What sorts of patients on your ward most benefit from your current weekend allied health service and how? What makes it effective or cost effective? |
3. | What are the disadvantages of the weekend allied health service? What do you think are the main threats to effectiveness or cost effectiveness? |
4. | Are there particular allied health services that are most valuable at the weekend for your ward, eg OT, Physio, SW? |
5. | Are there any duties/activities performed by weekend allied health staff that could be could be done earlier in the week? |
6. | Are there any duties currently performed by weekend allied health staff that could be done by others who are present during the weekend (e.g. nursing, medical staff)? |
7. | Are there any duties/activities performed by weekend allied health staff that could be put off until Monday? |
8. | What concerns do you have about the withdrawal of the weekend allied health service? What is the reasoning behind these concerns? Are they based on evidence, experience or something else? |
9. | Do you have any suggestions about how the weekend allied health service could be improved? |
10. | How easy or difficult do you think it would be to change procedures in order to make these improvements? |
11. | Are there any other comments you would like to make? |
Data analysis
Background, training, and preconceptions of investigators
Results
Sample characteristics
Themes common to all staff regarding the enablers of effective and cost-effective delivery of weekend allied health services
Patient flow, effects on length of stay, and resulting management pressure
Nurse (Hospital A): I know for a fact that we need allied health, and I know it (the removal of services as part of the trial) will affect discharges and patient safety.Occupational Therapist (Hospital B): the aim is to shorten the length of stay, so there are no gaps in patients' care…Earlier intervention allows earlier effectiveness of treatment and again facilitates discharge.
Nurse (Hospital B): it would be a shame to have a patient here that didn't really need to be, and sick people in the Emergency Department and ambulances backed up… I'm hoping (this trial) doesn't have that sort of effect.Occupational Therapist (Hospital B): Nobody wants to be in hospital longer than they need to be, in terms of that emotional well being and feeling like they're progressing. We don't want to keep them here any longer than they have to be.
NUM (Hospital A): the repercussions are I have to keep going back to these meetings (with executive management) and feeding back to these guys....Speech Pathologist (interrupts): We have targets for length of stay and if a patient stays longer than their target …NUM (interrupts): we lose money. After a certain amount of days we lose money, yes.
Quality, Safety, and continuity: Equity of patient care
Speech Pathologist (Hospital A): when it comes to understanding and making decisions or life-changing recommendations, (they need to be) based on an assessment that comes from a very informed background. Just like it wouldn't be very appropriate for us to start doing the doctors' work!Nurse 1(Hospital B): If a patient has had a decline on Friday evening … if we don't have a speech pathologist clearing them as safe to eat or drink, they'll stay nil orally until Monday.Interviewer: what are the consequences of being nil by mouth for that long?Nurse 2: malnutritionNurse 3: For some of the (nil by mouth patients) the doctors might be reluctant to put a (nasogastric tube) down because of advanced age or dementiaNurse 1: and on a weekend that decision won't be made. The after-hours covering doctor will say "we'll wait" and put intravenous fluids off until the speech pathologist (assesses them) on Monday.
Nurse (Hospital A): I suppose I find it stressful because to us, other than there is less staff around, the weekend is exactly the same. We still do theatre Saturday (and) Sunday; our patients are still sick all weekend. We still need just as much expert help on the weekend as we do during the week. Nothing actually changes. We don't close down beds; we don't stop operating. Saturday and Sunday is exactly the same as Thursday and Friday.
Preventing functional decline
Physiotherapist (Hospital A): (without weekend allied health) the patient just sits there - it's like two days rest, and it just puts them back again.Medical staff (Hospital B): They’re sitting in bed all day. You think about someone who’s quite old and hasn’t got much muscle anyway, they’re likely to decondition more easily especially over the weekend.
Reducing pressure on weekend nursing staff
Medical staff (Hospital B): There's a skeleton medical staff (on the weekend) and that can consume some extra nursing time, making it quite difficult for people to take on extra thingsNurse (Hospital A): I think we have enough to do. I think we already have too much to do! I see nursing in a rush. I see cut corners everywhere. I see quality of patient care replaced with quantity, and I see this increasing.Nurse (Hospital A): The physio getting (the patient) out of bed for the first time is important to us, because that is very time consuming for us (nurses) to do.... it gives us that time back to put back into our own clinical work.
Nurse (hospital A): most nurses pick up jobs, and try to do the best they can within the time and effort they've got, but it doesn't always work to the betterment of the patient. We're just not well enough qualified in that area; we do the best we can but we don't always make the best decisions
Themes specific to Medical staff
Ability to actively improve health of patients during their admission
Medical staff (Hospital B): if you get the patients up from day one, their lung function improves; they get better. It's not just preventing; we admit patients to hospital, and if we sit them down for three days in a hospital bed doing nothing, we're not actually doing anything for three days other than parking them in hospital with an oxygen tube and having some intravenous (medication) or whatever.Medical staff (Hospital B): all of allied health is very handy over the weekend, but the one we feel the most is definitely Physio. … We find a lot of our patients who are at high risk tend to go a bit backwards over the weekend quite a lot of the time, or at least don’t go forward. That holds up discharge and makes everyone’s life a bit more difficult.
Themes specific to nursing staff
The right person delivers the right service
Nurse (Hospital B): if you have junior (medical staff), or an intern on, and the registrar is really busy, and you have a patient who's a bit chesty it is a huge help to have a physio there to listen to their chest and help facilitate the care for that patient. That's more important on the weekend because we don't have all the medical staff on that we normally would.
Nurse (Hospital A): We don't have the necessary skills to know which is the appropriate gait aid to use so we'll just mobilize patients with two nurses rather than with the appropriate gait aid. (But the risks of this are) patients falling and nurses injuring themselves.
Nurse (Hospital B): Doctors want physios to do chest physio and I say to them, “We do chest physio, saline nebulizers, we do active breathing cycles, what further do you want? That patient is coughing and able to expectorate, they are doing bubble PEP, do we need to have physio on top of that? We can do that.”Nurse (Hospital A): if a nurse sees that the patient is having trouble in the shower or getting out of bed, we don’t have to wait for the physio or the OT, we can do that. We can make a decision. We can say, “yes, he walks safely” or “he can manage at home”.
Nurse (Hospital A): I think as a general nurse on the weekend, just to have the feeling of security, I guess. If you're having a physio or somebody available for whatever needs you've got, you know that you're having the proper assessment done, so that the patient's not at risk of falls or whatever. You know, you're going to have a proper gait aid … chosen for the patient and all the forms are documented and done properly. It gives you the security that you've done the right thing to prevent an injury.
Nurse 1 (Hospital A): (Social Workers) seem to know the right way to refer or the right avenue to refer our patients to the appropriate (services after discharge). Some things they can do that we as nurses cannot do.Nurse 2: Like domestic violence issues, child protection issues. They are very, very important. We get patients here who have been bashed or abused or something like that, and the patient's not safe to go back home. That's where the social worker is able to find that out and do something about it.
Minimize risk of harm with complex patients
Nurse 1 (Hospital B): It's just the discharges, from a legal side of things. If on a Friday the physio says "not safe for discharge" and then the next day they're walking around on their own, you know, where do you sit with that if they're doing everything for themselves but someone has written down "not safe for discharge"?Interviewer: How confident would you feel about reviewing that decision, considering the change in the last 24 h?Nurse 2: I think that's a seniority thing. I'd be happy, but …Nurse 1: sometimes the doctors say, " When cleared by allied health". We're not allied health.Nurse (Hospital B): What if, for example, (the patient) needs a shower stool and he's a young fit guy who's been on crutches for 6 weeks? Oh sure I can hand over a shower stool, but if he fell in that bathroom and came back in with a head injury, that concerns me. It's really not my qualification; you do years of university to be an occupational therapist and it is their specialty. Even though, in the back of my head I'm thinking, “this is all really simple”, there's something there saying, "I'm taking this responsibility,… this ownership; I'm then educating the patient, and I've now taken responsibility for this"… It's beyond my scope of practice.
Themes specific to allied health
Mitigating the risks associated with high workloads on Mondays and Fridays
Occupational Therapist (Hospital B): Fridays are a bit the same because you're not (going to be) here for 2 days, so there's this sense in the department that Fridays and Mondays are the worst days of the week.Physiotherapist: if you pick up a new patient at 3.30 on Friday, and there are issues, that's when you think "Thank God there's a weekend service so I can get them to follow them up".
Improved access to family/carers
Social Worker (Hospital A): A lot of time the families work from Monday to Friday… within the hours that we work. If we have (weekend staff)… within that time we can get (the family) to come in, (so we can) teach them about (things like) transfers, and equipment.Occupational Therapist (Hospital A):(on a weekend) we can talk to the patient and their carers and relieve any anxiety, provide information about what's available, talk about what they can link in with during the week and how they can do that.
Enhanced ability to meet care guidelines leading to better health outcomes
Speech Pathologist (Hospital A): Just recently a patient had had a stroke … and 2 days later I found out! The doctors said that they could eat and drink and they had been, but I thought OK, just because they haven't coughed, it doesn't mean that they're necessarily tolerating their diet or fluid. So … that's a risk there. You want to be able to see the patient and make sure they're going to be safe
Detecting or preventing errors that would otherwise be missed
Speech Pathologist (Hospital A): The national stroke guidelines, which we adhere to, (recommend that) the full allied health team sees the patient within 48 h of admission, and the MRI or CT should happen within the first four hours. Often we're the ones identifying things and pushing (for) the CT. The doctors should be on to it, but it is often allied health advocating (for it).
Themes common to all staff regarding the barriers to effective and cost-effective delivery of weekend allied health services
Financial cost
Physiotherapist (Hospital B): The cost of the service needs to be balanced against the savings they are making by discharging patients.
Insufficient investment to generate benefits
Weekend Speech Pathologist (Hospital B): You don’t have enough hours and so you are just doing the clinical risk stuff and that won’t have an impact on the length of stay because you’re not getting to the functional maintenance stuff.
Medical staff (Hospital A): (Weekend allied health) are possibly a little more time-pressured, and unable to guarantee to be able to do as comprehensive a review of the patient’s issues.Medical staff (Hospital B): If it’s not funded well, there is a service but it’s not doing what it could potentially do –it’s only got a very limited coverage
Discontinuity with community services on weekends
Medical staff (Hospital B): You just can’t push out certain cohorts of patients because other institutions, other facilities, other services don’t have (weekend) provision. So it works well for some patient cohorts, ones who perhaps, can go home independent or with family support. You can’t do that for every ward and every patient, so it’s about picking the right ward and the right patient …. Some you can’t move them on. It doesn’t matter if you see them on a Saturday or Sunday and deem them safe, they are still not going to go.Social Worker (Hospital A): one of the difficulties with discharge at the weekend might be that we can’t contact service providers on the weekend so if you have a service that needs to start on the day that the person is discharged, they may not be appropriate for a weekend discharge. Or in terms of social work and liaising with community, that might be something that can’t be done on the weekend.
Themes common to nursing and allied health
Duplication of effort
Nurse (Hospital A): A lady who was about to be discharged asked to see a social worker, so we called the social worker on call but they couldn’t arrange anything because there is nothing open on the weekend anyway. So then that still has to wait until Monday before it can be sorted out.Dietitian (Hospital A): I am (often) referred patients (at risk of refeeding syndrome) just to check bloods and I think, “that’s not a good use of our service”. If pathology are picking up that someone’s potassium is super low, they don’t need a dietitian as the middleman – they can go straight to the doctor.Dietician (Hospital A): If someone starts something on the weekend, then we have to reassess anyway in terms of interpretation and things like that
Employment of under-skilled/inexperienced staff
Physiotherapist (Hospital B): staff that work on the weekend are junior… and they don’t have the experience to decipher (the urgency of a referral) with a quick read of the notes – they’ll take an hour and write a page of notes where that could have been done on a Monday.
Unnecessary interventions, inappropriate referrals, or both?
Physiotherapist (Hospital B): Does (our intervention) actually have an impact or not? How do we know that we are providing the best care by seeing them day one post-op or not? It's really making me question whether the physio referrals, or the patients that we were seeing, whether they were appropriate or not. Or whether we need to carefully look at our referral criteria … and what patients should be seen on the weekend.
Physiotherapist (Hospital B): I think there is a lack of clarity about what kind of patients should be referred to the weekend physio service and we often get completely inappropriate referrals and then don’t get the people that should be (referred).
Nurse (Hospital B): If (the physio) is busy elsewhere, then … I'm feeling that they're saying they won't come because they're low on the priority list. So what IS the priority list from physio's point of view?Interviewer: and that's not clear to you - how they priorities patients?Nurse: No. Clearly if (a patient) came out of ICU, then yes they would need to see them if they have a tracheostomy. … Otherwise … sitting them out of bed, ambulation, that (seems to be) low on their priority.
Weekend staff who are risk-averse, unfamiliar with the ward or patients
Occupational Therapist (Hospital A): We have staff that work here on the weekends that don’t work during the week. We need to be very careful with clinical handovers to get the job finished off. Weekend staff are often from different organizations so don’t know our procedures all that wellNurse 1 (Hospital A): They don’t really know the patient so they need our input – lots of our input - to make a decision and sometimes they can’t make a decision. They leave it for the next dayInterviewer: so they hold it over to the weekday staff?Nurse: I’ve seen it happen – they can’t make decision even if the (weekday) physio has said, “OK for discharge” they say, “I don’t know! I think we’ll wait for tomorrow”…they don’t work here during the week; …they don’t want to take a risk.
Themes specific to allied health
Difficulty finding and keeping weekend staff with the right skill mix
Speech Pathologist (Hospital A): Our clinicians on the weekend have to understand the whole gamut of patients because they are working hospital wide – it’s hard to get adequately skilled staff across the continuum.
Speech Pathologist (Hospital A): Weekend staff do not participate in mandatory training and so feel quite fragmented and removed from the rest of the team. From a safety and a “roundness’ of experience, having access to training would be fantastic…. Some may be stay at home mums during the week and the last training they went to was 5 years ago.