This Signal relates to delay in emergency surgery because of distance to travel from hospital for key on-call staff, including non-medical staff such as theatre nurses.
It is a national requirement for key medical staff to live at a reasonable distance/time from their main place of work for emergency on-call needs. Local organisations also need to ensure that other key on-call staff are available.
Extract from incident reported to the RLS:
“Standby call for 8 year old child, status fitting for the past 30 minutes. On arrival, GCS 3 paed crash call and anaesthetics. Seen by paed reg for urgent CT scan. CT request booked with radiology reg at 10.30hrs…eventually radiology consultant..arrived at 12.50hrs. The amount of time of two and a half hours of awaiting radiologist arrival could have had a severe impact on his recovery. On call should be within an hour’s travel time to [xx hospital] as delay in some scans could be the matter of life or death and this needs to be addressed before the next incident form states died awaiting CT.”
The trigger incident was a coroner’s rule 43 letter reviewed by the National Reporting and Learning Service (NRLS) which identified a delay in emergency attendance of consultant surgeon and anaesthetist as contributing to the patient’s death. Both staff lived over 40 miles from the hospital.
The national incident database identified 13 reports where distance from clinical site was noted as a factor in delay. While none were reported as contributing to patient’s death, the incidents reflect a number of serious near misses. Key staff identified included nurses, community midwives and other staff as well as medical consultants (obstetrics, surgery, anaesthesia, radiology).
One issue appeared to be on-call staff (especially non-medical) for second theatres:
“Two emergencies booked with theatre at 15.00. Request from consultant neurosurgeon and consultant general sugeon to open second emergency theatre. Anaesthetic staff, surgeon and scrub staff available for both cases but no ODP. ODP on call for second theatre lives in xx! (35 miles from hospital)… Treatment of general surgical patient (already waiting >24 hr for emergency surgery) delayed further because of unavailability of on-call ODP. What would have happened if second theatre needed for immediately life-threatening haemorrhage?”.
The National Consultants Contract in England (Schedule 12, para 2) states that consultants should live within 30 minutes or ten miles by road from their main place of work, unless negotiated differently with the employer.
In Wales, the 2004 Amendment to the National Consultant Contract in Wales states: 'It is recognised that the old 10 mile limit on how far away a consultant can live, is no longer appropriate - the time taken to be able to return to the relevant site(s) for emergency work purposes now being the necessary consideration.”
For other staff, there are no national policies and local employers should set appropriate guidelines.
Organisations should review local policy and practice:
- How long does it take your on-call staff to attend for emergencies?
- How far away do they live?
- Can your escalation plans cope with these?
- Does it cover all key staff, not only medical (for instance, scrub/anaesthetic practitioner as well as surgeon)?
- Have you had any serious near-misses with delay to emergency surgery or diagnostic procedure out of hours?
Let us know if you have learning to share (email@example.com).
Relevant to: Acute hospital setting - and all specialties with acute (emergency) on-call requirements.
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