Doctor-patient ratios and acute medical admissions: a simple solution for an important problem!

Editor,

There has been a 9% rise in the number of hospital admissions under acute care over the last 5 years in Northern Ireland and majority of these are over 65 years of age and with complex needs1. The medical admission process has considerably improved over the years with introduction of proformas and risk assessment tools. Both these factors have contributed to an increase in workload for doctors undertaking acute medical admissions. Over a quarter of medical registrars throughout UK reported an unmanageable workload and about 66% reported it as heavy as per the recent survey conducted by the Royal College of Physicians2.

At a recent audit meeting within our hospital, a number of clinical incidents concerning the initial admission process were highlighted. These included incomplete venous thromboembolic risk assessments, poor record of medications and, prescription errors. Majority of these incidents happened during night shifts. We hence undertook a project to ascertain the reasons for this by specifically looking at the distribution of doctors.

We retrospectively analysed all acute medical admissions during the month of January 2013 in our hospital particularly focussing on their distribution over a 24-hour period. We divided 24-hour period into 4 shifts (8am-1pm, 1pm-5pm, 5pm-9pm and, 9pm-8am) as the number of doctors varied during these time periods as per the existing shift rota. Data was obtained from electronic patient management system (ePMS, Healthintec) and statistical analysis performed using Microsoft Excel (version 2010).

1,092 admission episodes were included in the study. The average number of admissions in a 24-hour period were 35, of which 40% (n=14) were during night shift (9pm-8am). Although the total numbers of doctors seemed adequate, we found a significant disparity in the doctor-patient ratios among different shifts i.e. the average number of medical admissions and the number of doctors on various shifts (Figure 1). We also found that there was an upward trend in the average time taken to assess patients following a referral over a 24 hour period with a difference of approximately 40 minutes between day (8am-9pm) and night shifts (9pm-8am) (Figure 2). Moreover, majority (64%) of the 4-hour breach times in commencing initial assessment occurred during night shifts (9pm-8am).

Figure 1

Average patient and doctor numbers during various shifts in a 24-hour period.

Figure 2

Average time taken to assess patient from the time of emergency department referral. (Shifts on the X-axis and Time (in hours: minutes: seconds) on the Y-axis).

Our analysis showed that during night shifts the numbers of doctors were disproportionately lower with respect to the clinical need. Following this project we recommended a redistribution of doctors to increase their number during night shifts. This was possible without affecting the working hours and the banding requirements. We believe that by improving doctor-patient ratios we can reduce the individual workload thereby giving doctors more time to ensure adequate completion of the initial admission proformas. We hence recommend that all hospitals should undertake similar projects by looking at the distribution of admissions and doctors, and introducing this simple solution towards improving delivery of patient care and safety.