Hot and cold teams: Improving trainee experience, enhancing patient care

Overview of the project

The quality improvement project arose from recognition that, nationally, there is a dip in the quality of patient care and there is a lack of junior doctor supervision and training at weekends. Additionally, before the pilot project, trainees on the medical rota were on-call cyclically. Pressure in the acute and emergency departments meant that trainees were often pulled from the wards or felt unable to leave the emergency areas to support colleagues on the wards. This meant doctors in training sometimes felt unsupported and too busy to undertake Workplace Based Assessments (WBAs) or maximise learning opportunities such as attending clinics.

The quality improvement project aimed to redesign the current service model to maximise opportunities for learning and thereby improve the service. They did this by establishing hot ‘emergency-based’ and cold ‘ward-based’ teams to enhance the trainee experience and improve patient care at weekends.

Project team

The project team was consultant-led and multi-professional, including trainees and a patient representative. All staff were involved so everyone felt instrumental in implementing change and feeding back ideas.

Methodology

A customised, electronic rota system was introduced which revised the rota for trainees in medicine. On the new rota trainees spent four weeks as part of the ‘hot’ team and 12 weeks in the ‘cold’ team.

Whilst part of the ‘hot’ team, trainees worked in Accident and Emergency, Emergency Admissions Unit and the Clinical Decisions Unit. This offered them an intense learning experience in terms of dealing with the acutely ill patient without being pulled to the wards, which enabled them to gain key competencies with close support of seniors. All doctors’on-calls were completed during this period.

During the ‘cold’ period, trainees worked on the medical wards where they were able to maximise learning opportunities by attending clinics, practising procedures and undertaking WBAs.

The pilot also funded the creation of an enhanced cold team working at weekends, with an additional registrar to work exclusively on the wards, to support to the doctor in training and improve patient safety; and an additional Band 6 senior nurse and extra phlebotomy support, which relieved pressure on the doctor in training. This has radically altered the on-call weekend experience. For example, reducing delayed discharge of patients waiting for blood tests and freeing up trainee time to enable them to undertake WBAs.

Challenges

There were challenges in introducing change. Six months into the pilot it was recognised that annual leave and study leave needed to be fixed in the cold block, to enable the ‘hot team’ to function effectively. However, Consultant Dr Prathibha Bandipalyam who led the project was an inspiring champion who engaged doctors in training and allied healthcare professionals at a clinical level, which made change easier to implement. Support from managerial and administrative levels of Medical Education and the Urgent Care and Long Term Conditions Division made implementation and evaluation smoother and ensured sustainability.

Results

The project led to better patient outcomes and better education and training.

Quantitative data was collected from existing sources and found that length of stay was reduced and weekend discharge rates increased. There were also no Serious Untoward Incidents involving trainee doctors in medicine during the pilot. The number of WBAs completed and clinics attended by trainees increased. Focus groups and questionnaires were conducted to gain qualitative feedback from all members of the multidisciplinary team. The project was well received and trainees reported feeling more supported and having more opportunities for training. The cultural change was marked, with everyone becoming really involved and helping lead the project. The benefit to the trust is clear because they continued to fund the additional staff at weekends after the pilot ended.

Conclusions

The project enhanced the support and training for junior doctors, especially at weekends, by providing enhanced senior and multi-professional support. It improved the care and safety of patients, by enhancing supervision, ensuring that timely review of patients and maximising learning opportunities for trainees.

Future

Since the HEE BTBC project has finished the new model has been maintained and continues to work successfully in medicine. Following its success it is being rolled out across hospitals in the East Kent Hospitals University NHS Foundation Trust. The project has the potential to be adapted locally in other hospitals across the UK.