Question 6

College answer

Not available.

Discussion

Though a trainee, upon reading the stem, would likely develop the broadest grin ("Good! make the bastards do some work"), there may be some unintended consequences to this decision. Reading the question requires some care. "Outline important aspects" does not mean "Fashion a mature administrative approach and detailed plan of implementation in the space of ten minutes", as none of the people writing this exam are going to be ICU directors. Nor, for that matter, could any ICU director cobble together a workable strategy and put it coherently on paper within the timeframe afforded by this SAQ. There must, therefore, be two possible types of answer here: one which is concise and basic, i.e what can be expected from the stressed exam candidate, and one which is a thoughtful and considered response to the problem as it is phrased. Unfortunately, what follows is neither one nor the other. A rambling and incoherent attempt at a detailed discussion of this subject can be found at the end of the chapter on ICU design and staffing, but the time-poor candidate is instructed to ignore it. Because there is no official college answer, the author has created this response from nothing, on the basis of no specific knowledge or experience. 

Rostering aspects: decisions need to be made:

• How many hours are worked per evening shift
• How are these remunerated
• Roster needs to prevent excessive working hours
• Leave accumulation / time in lieu needs to be decided
• Number of senior staff may need to increase to cover the extra clinical hours

Logistic aspects

• Space for the after-hours staff needs to be allocated
• Sleeping quarters or break facilities may need to be expanded.
• If more intensivists are needed to staff the roster, they will need offices, an increase in the administrative capacity (eg. hiring more secretaries), etc. 

Clinical governance aspects need to be decided:

• Who takes responsibility for after-hours patient management (eg. everybody must agree that they trust each other to manage each other’s patients, which means the evening intensivist takes responsibility for the unit in the evening)

Patient safety aspects

• Clinical handover will need to be coordinated between day and evening staff, for continuity of care to be preserved
• The junior ICU medical staff and ICU nurses need to know whom to contact, and there needs to be clear guidance provided to them
• The breadth of cover should comply with CICM safety regulations (section 6.2.5 of IC-1), which recommend that "after hours it is acceptable for one intensive care specialist to manage two such pods [16-30 patients in total]  provided there is an additional intensive care specialist on second call"

Staff safety aspects

• The evening roster needs to protect the ICU staff from unsafe working hours
• A maximum number of evening shifts per annum or per month needs to be established in order to prevent burnout
• A sufficient recovery time should be afforded to the staff involved in the evening roster
• Nonclinical responsibilities will need to be suspended for the duration of the rostered evening shifts

Change management aspects

• Resistance is not unexpected, and is a predictable aspect of any change process. 
• The introduction of the roster needs to be handled carefully and collaboratively, by:
  • Introducing it in terms of the needs it addresses,
  • Establishing trust for the process through transparency
  • Building consensus for various elements of the implementation process
  • Planing the implementation together as a group
  • Setting up a clear timeframe for the implementation
  • Communicating the steps in this process widely, including senior hospital administration, junior medical officers, and nursing staff

Audit and monitoring

• Identity the incidents or processes which led to the decision to change the roster pattern
• Identify measures of the expected benefit of the roster (eg. procedure complicaiton rates)
• On the basis of these, create objectively measurable variables
• Measure these prospectively during the period of implementation
• Compare these measurements to a retrospective audit of pre-change practice
• Assess the efficicay of the new roster using this comparison
• Regularly re-audit this process to produce incremental improvement in practice