August deaths caused by “poor prioritisation”

THE increase in patient deaths during the August trainee changeover is due to poor prioritisation and a failure to recognise deteriorating health, according to a new study.

The so-called “August effect” can also be linked to trainees making mistakes as they adjust to their new roles.

The rise in mortality associated with the August jobs changeover is not caused by trainees working more slowly or coping with a heavier workload, researchers found.

The researchers, writing in JRSM Short Reports, produced by the Journal of the Royal Society of Medicine, said improved training and quality control were needed to address the issue.

They based their findings on data drawn from a wireless out-of-hours system at two hospitals in Nottingham which records the number and type of tasks requested by nurses. They monitored almost 30,000 tasks completed between June 1 and August 31, 2011 at City Hospital and Queen’s Medical Centre. The teaching hospitals have around 1,700 beds in 87 wards, handling around 190,000 acute attendances a year.

The study sought to find out whether the out-of-hours workload increased after changeover, which would suggest inefficiencies and tasks not completed during dayshifts. They also looked for evidence of more urgent out-of-hours work, implying a failure to identify deteriorating patients or major omissions in-hours. Finally, they looked to see if junior doctors were taking longer to complete out-of-hours tasks after changeover which would suggest inefficiency and delays were contributing to the "August effect".

The study concluded that, while total workload does not change greatly around junior changeover, the proportion of urgent tasks increases significantly. Time to complete non-urgent tasks fell after the changeover.

The report stated: “These results suggest that the 'August effect' of increased morbidity and mortality is not driven by new junior doctors working more slowly or by an increase of overall workload.

"[T]his pattern could have arisen through omissions, errors, failure to recognise deterioration, and poor task prioritisation skills. These factors are amenable to improved training, supervision, and quality control."

Researchers also stated that, if their findings were confirmed by future research, there could be scope to improve the quality of in-hours care to reduce the number of urgent tasks and the associated patient risks.

They added: "Certainly, the current approaches to readying students for their first day on the wards have been heavily criticized despite the increased use of shadowing periods."