AAGBI14.10 Out of Hours Activity (Anaesthesia)
AAGBI14.10 Out of Hours Activity (Anaesthesia)
AAGBI14.10 Out of Hours Activity (Anaesthesia)
(Anaesthesia)
Guiding Principles and Recommendations
October 2014
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Definitions
The times that can be considered to be “out of hours” (OOH) may be defined contractually or by reference to
published national standards. In the current Consultant Contracts for England and Wales, OOH is defined by
the concept of “premium time”, i.e. that which is outside of 07.00 h – 19.00 h on non-Bank Holiday weekdays.
Current and future contract negotiations may change the periods covered by “premium time”. The National
Confidential Enquiry into Patient Outcome and Death (NCEPOD) defines OOH as: “any time outside 08.00 to
17.59 on weekdays, and any time on a Saturday or Sunday”. We will simply define OOH work as that done
outside of the normal working week.
Emergency work
Anaesthetic services delivered OOH are key to the provision of emergency care. Anaesthetists will
reasonably be expected to provide OOH cover for cases that come under the NCEPOD Classification of
Intervention as being “Immediate” or “Urgent”. Following clinical assessment, those cases classified as being
“Expedited” or “Elective” need not be done OOH. Immediate or urgent cases should be prioritised over
routine / elective care at all times.
Patient considerations
Patients should receive appropriate treatment to national standards of care from competent and fit–for-work
clinicians in a timely fashion. However, there must be a balance between the need for speed with which
urgent and expedited surgery is performed in order to minimise the pain and anxiety, and the need to
maintain standards of safety if the provision of OOH is increased. Patient safety must always be prioritised
over patient convenience.
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Considerations for anaesthetists
The implementation of the Working Time Regulations (WTR) means that trainees no longer work excessive
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hours, although the shift patterns worked by the substantial majority do lead to fatigue . Decreases in trainee
hours and overall numbers as well as an increasingly elderly population with greater co-morbidities mean
that career grade doctors, i.e. Consultants and Specialty Doctors, are doing an increasing proportion of OOH
work. As career grade doctors can derogate from WTR, there is a risk that pressure may be exerted to
increase both the amount of work performed and the proportion of work that is done OOH, and the current
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government has signalled its intention to look again at the application of WTR to trainees . The ability to
recover from sleep deprivation deteriorates with age, and particular attention should be paid to the impact of
excessive or irregular working hours on the older anaesthetist. It is essential that all anaesthetists are aware
of the potential impact of fatigue on their cognitive ability and ensure they are well rested before treating
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patients . Careful planning is required so that patient risk is not increased as a result of fatigue. Specialties
that conduct larger proportions of their clinical activity OOH may experience problems in recruitment and
retention.
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Members of the working party:
Dr Kathleen Ferguson (Chair), Dr Ramana Alladi, Dr Les Gemmell, Dr William Harrop-Griffiths, Dr Richard
Griffiths, Dr Barry Nichols, Dr Anna-Maria Rollin,Dr Caroline Wilson, Dr David Whitaker
References
1. Folkard S,Tucker P. Shift work, safety and productivity Occupational Medicine 2003; 53; 95‐101.
2. Howard SK, Rosekind MR et al. Fatigue in anaesthesia. Anesthesiology 2002; 97; 1281‐1294.
3. Fatigue and Anaesthetists 2014.
http://www.aagbi.org/sites/default/files/Fatigue%20Guideline%20web.pdf
4. Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, Landrigan CP. Effects of health care
provider work hours and sleep deprivation on safety and performance. Joint Commission Journal on
Quality and Patient Safety 2007; 33: 7-18.
5. https://www.gov.uk/government/news/more-flexibility-for-nhs-doctors-under-european-working-time-
directive accessed September 2014