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Emergency On-call Duties
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Key Words Audit, on-call, standards of practice, Association of Chartered Physiotherapists in Respiratory Care.
Emergency On-call Duties
by Tracy Dixon Julie C Reeve
Audit of support, education and training provision in one NHSE region
Summary The purpose of this audit was to investigate the post-registration support, education and training available for physiotherapists in one Regional Health Authority before they undertook emergency on-call duties. Practice was audited against agreed standards of practice established by the Association of Chartered Physiotherapists in Respiratory Care. A postal questionnaire was sent to 20 large general hospitals in the NHS Executive Trent Region. A response rate of 90% (n = 18) was achieved. Awareness and adherence to the standards was evident in all the physiotherapy departments investigated. The standard least adhered to was that which suggests there should be an agreed level of staff training before starting on-call duties. This study demonstrates that support, education and training provided to physiotherapists within the Trent Region are in widespread agreement with the standards of practice of the Association of Chartered Physiotherapists in Respiratory Care, but provision varies between units.
Dixon, T and Reeve, J C (2002). ‘Emergency on-call duties: Audit of support, education and training provision in one NHSE region’, Physiotherapy, 89, 2, 104-113.
Introduction Once qualified, physiotherapists are expected to help to deliver an emergency service for acute respiratory patients. During such duties they are expected accurately to assess and identify patients' problems, use this information to determine and evaluate the nature and extent of their problems, implement specific treatment programmes and demonstrate a sound rationale for choice of interventions. Provision of this service is most often by means of a departmental emergency on-call rota, usually involving physiotherapists working in isolation. While no study has isolated the impact of undertaking on-call duties on the stress levels of physiotherapists, Mottram and Flin (1988) demonstrated the treatment of critically ill patients to be a key stress factor for newly qualified physiotherapists. They considered the impact of this stress might result in altered job performance and difficulty in adjustment to the
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professional role. Strategies for guidance, support and training may help alleviate this and the use of guidelines, protocols and standards should help departments in the development of these strategies. Guidelines, protocols and standards provide explicit statements of expected practice performance and aim to achieve widespread adoption of best clinical practice (Buttery, 1998). They should be based on the best available evidence and in the absence of this evidence should be based on expert opinion, patient or professional experience, or consensus (Mead, 1998). The Association of Chartered Physiotherapists in Respiratory Care is a national Clinical Interest Group recognised by the Chartered Society of Physiotherapy as an expert body in cardiopulmonary physiotherapy. With its commitment to the development, maintenance and promotion of high standards of respiratory care, the Association of Chartered Physiotherapists in Respiratory Care published Standards for Respiratory Care (1996). Fifteen statements were produced in response to a need to define good physiotherapy practice and document national standards in respiratory care. Each statement has criteria against which practice can be audited. Standard 9 addresses the provision of emergency duty respiratory physiotherapy. It comprises eight criteria against which good practice can be monitored (see box 1). The emergency duty standard has been documented to help both new graduates and those physiotherapists not routinely working in the field of acute respiratory care. It provides criteria defining standards of support, education and training of staff before they take part in such duties. Audit aims to improve the quality and outcome of patient care through struct-
Audit
ured peer review whereby clinicians examine their practice against standards and modify practice where indicated (NHSE, 1996). Criterion-based audit is founded on the principle that it is possible to devise measurable criteria against which a valid reliable and quantitative assessment of individual and group per formance can be made in relation to a specific guideline, protocol or standard (HQQ, 1997). To date there has been only one published attempt to audit the use and implementation of the Association of Chartered Physiotherapists in Respiratory Care standards (Brown et al, 1997). This was in response to a motion at the Annual Representative Conference of the Chartered Society of Physiotherapy in 1992 which called for a national audit of emergency/on-call physiotherapy services throughout the United Kingdom. The Association of Chartered Physiotherapists in Respiratory Care agreed to undertake this, the aim being to audit whether physiotherapy provider units had the essential components of an emergency respiratory service against the Association of Chartered Physiotherapists in Respiratory Care standards. A questionnaire to all members of the Chartered Society of Physiotherapy was published in Physiotherapy Journal (ACPRC, 1994) and staff involved in both the organisation and provision of emergency services were asked to respond. The response to the audit was poor, with a total of 52 responses from all members. Lack of information identifying respondents meant that repetition of information from individual units could not be excluded. This poor ill-defined sample did not allow for any meaningful statistical analysis. Recommendations from this initial survey were to redesign the audit tool and re-audit a sample of senior respiratory staff. This audit undertook to fulfil these recommendations, focusing on the support, education and training recommendations of the standards; thus standard 9 and its associated criteria formed the basis of this audit. Other than the previous Association of Chartered Physiotherapists in Respiratory Care audit (Brown et al, 1997), to the authors’ knowledge only three published studies have investigated on-call practice, provision and efficacy. Ntoumenopoulos and Greenwood (1991) documented the
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ACPRC Standard 9: All patients requiring emergency physiotherapy out of normal working hours receive safe and effective treatment Criteria 1. There is evidence of an agreed written emergency protocol. The protocol may include: Method of referral Expected response time Organisational details – recording system, security, bleep system, travel arrangements, accommodation and reimbursement system. 2. There is an induction programme for all staff participating in the emergency duty rota. 3. All participating staff are trained to an appropriate agreed level in accordance with local requirements. Aspects requiring specific training may include: Assessment of the acutely ill patient Physiotherapy skills relating to respiratory care Use of respiratory equipment available Pain management Endotracheal suction Physiotherapy management of the ventilated patient 4. There is evidence of ongoing training for all staff participating in the provision of an emergency service. 5. There is experienced specialist support available for staff. 6. There is documentation of service use. Documentation may include: Appropriateness Response time Referral source – profession and specialty 7. The service is monitored in accordance with local requirements. 8. There is evidence of the follow-up of inappropriate use of services.
Box 1
hours of provision of cardiothoracic physiotherapy services across Australia and how these services were organised. An incidental sample of hospitals with intensive care units was used to investigate the variance of 24-hour physiotherapy provision. Findings indicated a wide variability in service with 43% (n = 18) providing only normal working hours cover. This study looked solely at service provision and did not investigate explanatory, causal or practice issues. Jones et al (1992) further investigated chest physiotherapy practice in intensive care units in hospitals throughout Australia, the United Kingdom and Hong Kong. Provision of 24-hour on-call physiotherapy services varied between Physiotherapy February 2003/vol 89/no 2
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countries with 97% (UK), 49% (Australia) and 0% (Hong Kong) responders providing these services. A regular after-hours service was provided in 16% (UK), 41% (Australian) and 6% (Hong Kong) units. This study did not focus exclusively on oncall provision; it looked at numerous aspects of chest physiotherapy in intensive care units. It used small sample numbers in each country, with responders returning questionnaires per intensive care unit rather than per hospital. The questionnaire structure varied between countries making comparability of data incomplete in some cases. It made no attempt to investigate on-call provision in detail and did not consider on-call practice or procedures. More recently Ntoumenopoulos and Greenwood (1996) investigated the pro-
Section 1: Emergency duty protocol Q1 Does your department provide an emergency duty protocol for staff participating in the on-call rota? Yes – Please go to Q2 No – Please go to section 3 Q2 Which of the following statements best describes the emergency duty protocol within your department? There is an emergency duty protocol that is explained verbally to staff, but it is not documented in the written form There is a written emergency duty protocol clearly documented within your department Please state type of protocol if none of above are applicable
Q3 Which of the following areas are covered within your emergency duty protocol? Guidelines regarding expected response time following referral Documentation of patient assessment and treatment Security arrangements for the on-call physiotherapist The contact system, eg bleep or phone Necessary travel arrangements, eg hospital taxi service Accommodation arrangements whilst on-call Any remuneration / reimbursement system Information regarding available equipment A plan of the hospital Please state any other areas covered within the emergency duty protocol
Box 2: Examples of questions from the audit tool Physiotherapy February 2003/vol 89/no 2
vision of additional evening physiotherapy for post-operative pulmonary complications and intrapulmonary shunt (ventilation-perfusion mismatch) after abdominal surgery. Thirty-one elderly patients received either daytime only or daytime plus evening physiotherapy for up to 48 hours. Physiotherapy included combinations of positioning, gravityassisted drainage, breathing exercises, manual techniques, coughing and airway suctioning. Measurements (over 48 hours) included intrapulmonary shunt and incidence of post-operative pulmonary complications. The authors suggested additional evening physiotherapy might reduce post-operative deterioration in gas exchange after major abdominal surgery but that the effects of the individual physiotherapy techniques utilised were unclear. While this study went some way to analysing the effect of additional evening physiotherapy on short-term variables it did not address longer-term outcomes such as effect on length of stay in intensive care units or hospitals. The paucity of evidence in the provision, practice and effectiveness of emergency on-call physiotherapy duties requires attention and this audit was developed in an attempt to determine a baseline description of service provision, practice and adherence to national standards from which research investigating causation may be developed. The aims of this audit were therefore: 1. To audit current practice in the delivery of an emergency on-call service in one National Health Service Executive region against the Association of Chartered Physiotherapists in Respiratory Care standard 9 and its associated criteria. 2. To ascertain what support, education and training are currently provided for qualified physiotherapists in one Regional Health Authority before they take part in an on-call rota. Method Design and Implementation An audit of 20 hospital physiotherapy departments in the NHS Executive Trent Region was undertaken using a postal questionnaire to elicit information on emergency duty service provision, support and education for qualified physio-
Audit
therapists. Geographical location, ease of implementation, resource limitations and potentially faster response times were important considerations in deciding upon the audit tool. Standard 9 of the Association of Chartered Physiotherapists in Respiratory Care Standards for Respiratory Care was used as the basis for the audit. There is currently no nationally developed and validated tool available to audit these standards and thus the authors developed their own in the form of a postal questionnaire. This contained 21 questions with sub-sections relating directly to the criteria documented in standard 9. Examples of questions asked can be seen in box 2. For ease of completion and analysis, where possible a majority of closed questions were used to achieve a direct measure against the criteria (see question 1). Filtering was used to ascertain further details where necessary but exclude responses to inappropriate questions for others (see question 1). Additional information was collected via supplementary open-ended questions (see questions 2 and 3). The audit was distributed by post with a stamped addressed envelope to maximise response rate and on yellow paper to make it easier to read (Chesson, 1993). A covering letter was included to explain the purpose of the audit, identify the researcher and assure confidentiality. A number on the last sheet assisted with following up late responses and coded each questionnaire. Confidentiality was assured. Twenty-eight days were allowed for questionnaire completion and 15 were returned by the requested date, with a further three being returned following postal written reminders. Responses were available only to the authors and kept in a locked cabinet. At the time the project was undertaken, it was not obligatory to obtain permission from an NHS research ethics committee to question NHS staff. The proposal was approved through the approval process then in force in the university for undergraduate physiotherapy projects which took account of ethical issues such as the sensitivity of questions and the security of data as well as an assessment of risk. Sample There is little guidance on an appropriate sample size for audit purposes as the results will not be generalisable to other
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subjects. It seems that large numbers are not essential, between 20 and 100 usually being adequate (Buttery, 1998). The sample should be large enough to be confident that the obser ved level of compliance and any associated problems provide a reasonable reflection of reality. Twenty large acute trust hospitals from within the NHSE Trent Region were selected. All were between 500 and 1,000 beds, had physiotherapy departments, were teaching hospitals and had intensive care units. Senior I physiotherapists specialising in the field of acute respiratory care were invited to participate in the audit. Subjects were not selected randomly but formed a convenience sample from the target population. A pilot study was undertaken on two representatives of the target subject group at NHS hospital trusts outside the target region. The purpose of the pilot study was to identify any anticipated problems with ambiguity of instructions or questions. Comments on questionnaire design, content and problems with completion were sought. Minor changes to the layout and grammar were made. Data Analysis All raw data collected were of the nominal/ordinal level. Results were analysed and presented using a variety of descriptive statistical methods. Data analysis was done by hand owing to the small sample size. Results The results are presented in sections, each section representing a sub-section within the questionnaire. Response Rate Twenty questionnaires were distributed, and 18 were returned. This high response rate indicates excellent compliance and some reduction in bias of the sample (Oppenheim, 1992). Three were completed by superintendent physiotherapists and the remaining 15 by senior physiotherapists. Seventeen of the respondents were personally involved in preparing staff for participation in the on-call rota. Sixteen respondents were aware of the Association of Chartered Physiotherapists in Respiratory Care Standards for Respiratory Care.
Authors Tracy Dixon MSc MCSP is a senior physiotherapist in Westcotes Health Centre, Leicester. This article was written as part of her BSc honours degree, undertaken at Sheffield Hallam University. Julie Reeve MSc GradDipPhys is currently a senior lecturer in physiotherapy at Auckland University of Technology. She kindly provided supervisory and editorial support in her position of senior lecturer at Sheffield Hallam University from which she is currently on leave of absence. This article was received on April 19, 2001, and accepted on May 27, 2002. Address for Correspondence Tracy Dixon BSc MCSP, Senior Physiotherapist, Charnwood and Northwest Leicester Healthcare Trust, Westcotes Health Centre, Fosse Road South, Leicester LE3 0LP.
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General Information All respondents provided a physiotherapy service out of normal working hours (assumed to be from 8.30 am to 4.30 pm). This service took the form of an emergency call-out rota (referral by phone or bleep) in all departments, with six respondents offering no further means of service. Other types of emergency service provision can be seen in figure 1. Staff grades were required to participate in on-call duties in 17 hospitals. In three hospitals the only staff to undertake oncall duties were those who had completed a rotation or specialised in respiratory care. Four respondents did not use senior I physiotherapists as part of the on-call rota. One respondent used all staff and senior II physiotherapists but used senior I physiotherapists only if they specialised in respiratory care. Figure 2 illustrates at what stage physiotherapists were expected to undertake on-call duties. One respondent expected all new staff, regardless of grade and experience, to participate in on-call immediately following employment, but provided a training programme to support this.
Shift work
Planned call-out rota
Emergency call-out rota
0
5
10
15
20
Number of respondents
Fig 1: Type of emergency service available
Number of respondents
12 10 8 6 4 2 0 Specialist training
Immediately
After one rotation
Fig 2: Stage of staff physiotherapist participation in on rota call
Focus group
Senior I
Superintendent
0
2
4
6
8
10
12
Number of respondents
Fig 3: Responsibility for establishment of emergency duty protocol
Plan of hospital Available equipment Accommodation Security arrangements Response time following referral Reimbursement system
Section 1: Emergency duty protocols All respondents said they had an emergency duty protocol for physiotherapists participating in the on-call rota. Sixteen respondents had a documented protocol and one had an emergency duty protocol that was orally explained but not documented in writing. Figure 3 represents the grade of physiotherapist responsible for the establishment of the emergency duty protocol. Figure 4 highlights areas suggested by the Association of Chartered Physiotherapists in Respiratory Care to be covered within the emergency duty protocol and the percentage of hospitals adhering to these. Six respondents had all ten suggested areas covered within their protocol.
Travel arrangements Contact system Documentation of assessment and treatment Method of patient referral 0
10
20
Number of respondents
Fig 4: Areas covered within the emergency duty protocol
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Section 2: Induction programme before on-call duties All respondents reported a form of induction training programme available to physiotherapists. A formally organised induction programme, which all must attend before participating in emergency duties, was available in 14 hospitals with
Audit
Section 3: Level of training Agreed standards of practice for physiotherapists before participation in emergency duties were present in 11 hospitals. One respondent was in the process of reviewing practice and developing such standards. The remaining
12
10 Number of respondents
four hospitals providing training on an informal basis. Ten respondents covered all aspects recommended by the Association of Chartered Physiotherapists in Respiratory Care for inclusion in induction programmes. Reasons for non-adherence to suggested areas were not stated. Aspects other than those suggested by the Association of Chartered Physiotherapists in Respiratory Care included paediatric respiratory care (n = 3), specific medical conditions or pathologies (n = 2), cardiothoracic surgery and tracheostomy management (n = 1). Induction programmes involved the direct input of senior I respiratory clinicians in all hospitals. Nine respondents indicated senior I physiotherapists had sole responsibility for induction training. Seventeen hospitals offered some form of induction programme before expecting physiotherapists to participate in the on-call rota. Figure 5 illustrates those for whom respondents considered it necessary to undertake an induction programme. Additional responses included bank staff (n = 1), those returning to work following career breaks (n = 1) and senior clinicians working in other clinical areas (n = 4) to require induction training also. Length of time given to the induction programmes varied between respondents. Seven respondents provided induction training lasting from one to five working days. The option of completing one full rotation in respiratory care was available in some departments if this duration was subsequently found to be insufficient. Three respondents stated the induction duration for new staff before on-call duties depended purely on their past experience, knowledge and confidence. Six respondents indicated a period of more than five days induction training – the structure of this varied from two weeks based on an intensive care unit to eight weeks of lectures on an impromptu basis but including five days gaining practical experience.
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8
6
4
2
0 All new staff
Limited respiratory experience
Staff grades only
Fig 5: Staff receiving on-call induction
six hospitals had no agreed standards in place. Of those with agreed standards, formal assessment of achievement of these standards was poor. The majority of respondents used informal, subjective methods to measure competence including senior physiotherapist satisfaction, peer assessment by others in the induction group, and self-assessment. One respondent used a knowledge quiz. Competence was mainly assessed by senior I physiotherapists (n = 15). Section 4: On-going training All respondents stated some form of ongoing training in emergency duties was available for physiotherapists within their departments. The majority of departments (n = 11) implemented an optional ongoing training programme with resources available for continuing professional development opportunities. Training for physiotherapists in the form of a compulsory in-service training programme took place in seven hospitals. One respondent failed to answer the question. Ongoing training in emergency respiratory care occurred annually (n = 2), biannually (n = 4), monthly (n = 6) or weekly (n = 2). Four respondents provided training on request only and five units provided training on request in addition to their more formal ongoing training programmes. In 16 units, senior I respiratory therapists were responsible for ongoing training of staff participating in emergency on-call duties. Physiotherapy February 2003/vol 89/no 2
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Overall Compliance Key questions in each section of the questionnaire were used to ascertain overall compliance to Association of Chartered Physiotherapists in Respiratory Care criteria, summarised in figure 7.
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Number of respondents
10 8 6 4 2 0 All senior staff by phone
All senior respiratory staff by phone
Senior respiratory staff by phone or in person
Fig 6: Types of support available while on call
Experienced support available Agreed level of training Service monitored Documented protocol On-going training Induction 0
5
10 15 Number of respondents
20
Fig 7: General compliance with ACPRC standards
Section 5: Support available while on-call All respondents stated that some form of support was provided to physiotherapists during emergency duties. Figure 6 indicates the type of support available. Two respondents stated a senior physiotherapist would always work at weekends as back-up if an inexperienced member of staff was nominated as first-line cover. Sections 6 and 7: Documentation and monitoring of service Fifteen respondents monitored the emergency on-call service provided by their department in some way. Areas documented by respondents included patient assessment and treatment (n = 13), inappropriate call-outs (n = 3) and on-call response times (n = 3). Recipients’ evaluation of on-call training (n = 7), adherence to the emergency duty protocol (n = 10) and practice while actually on call (n = 10) were monitored. No hospital monitored the referrer satisfaction with the on-call ser vice provided. Other areas monitored included on-call usage trends, use of on-call rooms, workload on-call and cost (n = 1). Physiotherapy February 2003/vol 89/no 2
Discussion Where standards exist, compliance with them should be monitored and this forms an intrinsic part of the audit cycle. Monitoring should provide objective measures of how successfully the standard has been implemented in everyday clinical practice, identify reasons for any non-compliance or variance, and inform decisions about how to increase compliance (Buttery, 1998). Guidelines (standards and protocols – terms often being used interchangeably) provide evidence about expected practice and may be used in litigation proceedings, but compliance with guidelines does not defend against liability where these are inappropriately applied (Mead, 1998). Any non-compliance warrants further investigation but should be examined while considering applicability to local situations or individual patients. Practitioners have a responsibility to be aware of the existence of guidelines/standards/protocols and to make value judgements as to the applicability of these locally. This audit examined the local implementation of national standards but did not attempt to address the quality of the ser vice provision. Association of Chartered Physiotherapists in Respiratory Care standard 9 states that all patients requiring emergency physiotherapy out of normal working hours should receive safe and effective treatment. The associated criteria essentially reflect broad statements of service provision rather than considering the safety and effectiveness of interventions. While respondents may adhere to these broad standards, actual practice may vary and this should be audited in the future. Other forms of audit such as observation of practice, peer review, self-assessment and review of induction and training programmes should be undertaken. Physiotherapists’ rules of professional conduct (CSP, 1996) state that chartered physiotherapists shall practise only to the extent that they have established and maintained their ability to work safely and competently. The
Audit
responsibility for this within the on-call environment lies initially with physiotherapists but it requires provider units to monitor competency to practise and ensure service needs are met. Clearly identification of the quality of the service provision needs closer attention in future research. Despite a small sample size, a questionnaire response rate of 90% (n = 18) is considered good (Babbie, 1973) and suggests that the sample is representative of the target population studied. It may be suggested that the high response rate reflects the importance of this topic to the subject group, making it possible to identify general trends, educational opportunities, and variance in service provision within the target population. These results should not be extrapolated to the wider population and it is recommended that this audit should be replicated at a national level. The majority of our respondents were responsible for the training and support offered in preparing staff grades for participation in the on-call rota. This is a potential source of bias. As our study’s main aims sought a description of ser vice provision and adherence to standards, it was felt that senior cardio-respiratory clinicians were in the most appropriate position to provide the information. Future studies focusing on the quality of the service provided should seek wider views, including those from physio-therapists receiving training, those requesting oncall services, and patients. The results of our audit identify similar findings to those of the previous Association of Chartered Physiotherapists in Respiratory Care audit in 1996. It extended this by addressing not only which standards were being adhered to but also the underpinning practice used in implementation of the standards. It also examined the type and amount of support and training provided. This information has not been previously sought. Emergency Duty Protocols It is believed hospitals using therapistdriven protocols enhance practitioners’ per formance (Meredith et al, 1994). Written protocols should help provide a safe framework for basic practice, enabling clinicians to make clinical decisions within the scope of their own
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knowledge and experience. Our audit indicated that the emergency duty protocols in the sample studied offer guidance on service provision rather than guidance on patient care which would help clinicians in making decisions about appropriate treatments for specific conditions. Clinical guidelines provide recommendations for specific clinical inter ventions which have been systematically developed (Mann, 1996). Having clinical guidelines in place should help inexperienced physiotherapists in clinical decision-making. Professional groups should be working towards the development of these. Induction Programmes Reasons for the variance in the frequency, length, and content of training programmes between provider units, including the impact of these variations, require further investigation. Mead (1999) believes it is difficult to ensure the local use of specific national guidelines and it is therefore accepted that national standards may need adaptation to the local context where scope of practice, resources required and mode of practice will vary according to local conditions and demands. Our results demonstrated local variations and may show that inappropriate areas of practice are suggested within the Association of Chartered Physiotherapists in Respiratory Care standards or indicate that resources available (eg staff and time) for formal training in all suggested areas are impractical. Agreed Standards of Practice While determining whether respondents had agreed standards of practice before participation in emergency duties, our audit did not ascertain the variability or content of these standards between responders. However, the number of departments using formal methods to assess standards was disappointing. Achieving agreed standards before on-call duties should ensure safe, effective levels of practice. Competency-based testing may be one means of assessing standards in order to meet local requirements but this must include clinical decision-making and problem-solving strategies. Our results may highlight some of the conflicts and difficulties of assessing competency to practise in staff who may be recently Physiotherapy February 2003/vol 89/no 2
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designated fit to practise or professionally registered or have previous experience. The Chartered Society of Physiotherapy’s first rule of professional conduct (CSP, 1996) describes physiotherapists’ responsibility to maintain their competence to practise. With the clinical governance initiatives implemented from April 1999, physiotherapists, educators and managers must take increasingly seriously the need to demonstrate this competence. One of the key components of clinical governance is to ensure that those providing care are appropriately trained and have the skills and competencies required to deliver the care needed. These initiatives may enable compulsory regional or national programmes to be developed to ensure maintenance of a contemporary knowledge base, and address the difficulties inherent in assessment of competency. Clinical Interest Groups may need to consider their role in the development and implementation of nationally agreed standards in the future. Departments need to ensure that key advances, changes in practice and maintenance of professional skills are addressed by ongoing training and development programmes. Strategies for dealing with staff not reaching agreed standards were not sought in this audit but would provide valuable information for development of future guidelines. Specialist Support The fact that many respondents offered support for physiotherapists carrying out emergency duties demonstrates clear recognition of the stressful and specialist nature of the work and the necessity to provide on-the-spot support for less experienced staff. The level of take-up of this support was not investigated but may prove useful in further work. Documentation and Monitoring of Service Provision Areas monitored proved widespread but variable. Given current quality of care initiatives it is surprising that no respondent monitored referrer satisfaction. Procedural difficulties in referral,
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appropriateness of referral and satisfaction with the outcome of referral must be considered in the delivery of an emergency service from both consumers’ and providers’ perspectives. Monitoring of inappropriate use of on-call services and strategies for dealing with these require further investigation. These aspects of service provision should be key areas for audit given the current pressures on healthcare resources. Documentation of physiotherapy call-outs should be considered fundamental for audit, research and legal purposes. Conclusion This audit has demonstrated differing levels of support, education and training for physiotherapists before participation in emergency duties. This consists of an induction programme in all units, guidance in the form of written protocols, regular in-service training and, in the majority of departments, senior support while on-call. It has also shown that all junior physiotherapists working within the Trent Region are expected to participate in the delivery of an emergency respiratory care service. It has shown current practice in the delivery of an emergency physiotherapy service in the Trent region to be broadly in agreement with standards for emergency duty care suggested by the Association of Chartered Physiotherapists in Respiratory Care, but that compliance with individual criteria is inconsistent throughout the chosen sample. This variability indicates the necessity for review and development of more specific guidelines. Clinical Interest Groups should be involved in the further development of these. Key future work needs to widen the sample audited in this study. It should address the quality of practice as well as service provision and examine whether Association of Chartered Physiotherapists in Respiratory Care standards of practice are adequate for the needs of patients, physiotherapists and other health care providers. Audit of other Association of Chartered Physiotherapists in Respiratory Care standards should also be undertaken.
Audit
References Association of Chartered Physiotherapists in Respiratory Care (1994). ‘Emergency duty audit’, Physiotherapy, 80, 9, 621-622. Association of Chartered Physiotherapists in Respiratory Care (1996). Standards for Respiratory Care, ACPRC, London. Babbie, E R (1973). Survey Research Methods, Wadsworth, California, pages 159-170. Brown, A, Hinton, F and McMullin, E (1997). ‘Emergency duty audit by the ACPRC’, Journal of the Association of Chartered Physiotherapists in Respiratory Care, 30, 33-34. Bury, T and Mead, J (1998). Evidence-based Healthcare, Butterworth Heinemann, Oxford. Buttery, Y (1998). ‘Implementing evidence through clinical audit’ in: Bury, T and Mead, J (eds) op cit, chap 9, pages 182-207. Chartered Society of Physiotherapy (1996). Rules of Professional Conduct, CSP, London. Chartered Society of Physiotherapy (1999). ‘Annual Representative Conference motion 23’, Physiotherapy Frontline, 5, 6, 18. Chesson, R (1993). ‘How to design a questionnaire’, Physiotherapy, 79, 10, 711-713. Healthcare Quality Quest (1997). ‘Getting audit right to benefit patients’, HQQ. Jones, A Y M, Hutchinson, R C and Oh, T E (1992). ‘Chest physiotherapy in intensive care units in Australia, the UK and Hong Kong’, Physiotherapy Theory and Practice, 8, 39-47.
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Mann, T (1996). Clinical Guidelines: Using clinical guidelines to improve patient care within the NHS, Department of Health, London. Mead, J (1998). ‘Developing, disseminating and implementing clinical guidelines’ in: Bury, T and Mead, J (eds) op cit, chap 8, pages 162-181. Meredith, R L, Pilbeam S P and Stoller, J K (1994). ‘Is our educational system adequately preparing respiratory care practitioners for therapist-driven protocols?’ Respiratory Care, 39, 7, 709-711 Mottram, E and Flin, R H (1988). ‘Stress in newly qualified physiotherapists’, Physiotherapy, 74, 12, 607-612. NHS Executive (1996). Clinical Audit in the NHS. Using clinical audit in the NHS: A position statement, Department of Health, London. Ntoumenopoulus, G and Greenwood, K M (1991). ‘Variation in provision of cardiothoracic physiotherapy in Australian hospitals’, Australian Journal of Physiotherapy, 37, 29-36. Ntoumenopoulos. G and Greenwood, K M (1996). ‘Effects of cardiothoracic physiotherapy on intrapulmonary shunt in abdominal surgical patients’, Australian Journal of Physiotherapy, 42, 297-303. Oppenheim, A N (1992). Questionnaire Design, Interviewing and Attitude Measurement, Pinter Publishers, London.
Key Messages ■ Junior physiotherapists are expected to participate in the delivery of an emergency physiotherapy service. ■ Support, education and training for physiotherapists before participation in emergency duties is variable.
■ Variability in support, education and training provided indicates the necessity for review and development of more specific guidelines. ■ Quality of practice as well as service provision needs to be reviewed.
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Key Words Audit, on-call, standards of practice, Association of Chartered Physiotherapists in Respiratory Care.
Emergency On-call Duties
by Tracy Dixon Julie C Reeve
Audit of support, education and training provision in one NHSE region
Summary The purpose of this audit was to investigate the post-registration support, education and training available for physiotherapists in one Regional Health Authority before they undertook emergency on-call duties. Practice was audited against agreed standards of practice established by the Association of Chartered Physiotherapists in Respiratory Care. A postal questionnaire was sent to 20 large general hospitals in the NHS Executive Trent Region. A response rate of 90% (n = 18) was achieved. Awareness and adherence to the standards was evident in all the physiotherapy departments investigated. The standard least adhered to was that which suggests there should be an agreed level of staff training before starting on-call duties. This study demonstrates that support, education and training provided to physiotherapists within the Trent Region are in widespread agreement with the standards of practice of the Association of Chartered Physiotherapists in Respiratory Care, but provision varies between units.
Dixon, T and Reeve, J C (2002). ‘Emergency on-call duties: Audit of support, education and training provision in one NHSE region’, Physiotherapy, 89, 2, 104-113.
Introduction Once qualified, physiotherapists are expected to help to deliver an emergency service for acute respiratory patients. During such duties they are expected accurately to assess and identify patients' problems, use this information to determine and evaluate the nature and extent of their problems, implement specific treatment programmes and demonstrate a sound rationale for choice of interventions. Provision of this service is most often by means of a departmental emergency on-call rota, usually involving physiotherapists working in isolation. While no study has isolated the impact of undertaking on-call duties on the stress levels of physiotherapists, Mottram and Flin (1988) demonstrated the treatment of critically ill patients to be a key stress factor for newly qualified physiotherapists. They considered the impact of this stress might result in altered job performance and difficulty in adjustment to the
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professional role. Strategies for guidance, support and training may help alleviate this and the use of guidelines, protocols and standards should help departments in the development of these strategies. Guidelines, protocols and standards provide explicit statements of expected practice performance and aim to achieve widespread adoption of best clinical practice (Buttery, 1998). They should be based on the best available evidence and in the absence of this evidence should be based on expert opinion, patient or professional experience, or consensus (Mead, 1998). The Association of Chartered Physiotherapists in Respiratory Care is a national Clinical Interest Group recognised by the Chartered Society of Physiotherapy as an expert body in cardiopulmonary physiotherapy. With its commitment to the development, maintenance and promotion of high standards of respiratory care, the Association of Chartered Physiotherapists in Respiratory Care published Standards for Respiratory Care (1996). Fifteen statements were produced in response to a need to define good physiotherapy practice and document national standards in respiratory care. Each statement has criteria against which practice can be audited. Standard 9 addresses the provision of emergency duty respiratory physiotherapy. It comprises eight criteria against which good practice can be monitored (see box 1). The emergency duty standard has been documented to help both new graduates and those physiotherapists not routinely working in the field of acute respiratory care. It provides criteria defining standards of support, education and training of staff before they take part in such duties. Audit aims to improve the quality and outcome of patient care through struct-
Audit
ured peer review whereby clinicians examine their practice against standards and modify practice where indicated (NHSE, 1996). Criterion-based audit is founded on the principle that it is possible to devise measurable criteria against which a valid reliable and quantitative assessment of individual and group per formance can be made in relation to a specific guideline, protocol or standard (HQQ, 1997). To date there has been only one published attempt to audit the use and implementation of the Association of Chartered Physiotherapists in Respiratory Care standards (Brown et al, 1997). This was in response to a motion at the Annual Representative Conference of the Chartered Society of Physiotherapy in 1992 which called for a national audit of emergency/on-call physiotherapy services throughout the United Kingdom. The Association of Chartered Physiotherapists in Respiratory Care agreed to undertake this, the aim being to audit whether physiotherapy provider units had the essential components of an emergency respiratory service against the Association of Chartered Physiotherapists in Respiratory Care standards. A questionnaire to all members of the Chartered Society of Physiotherapy was published in Physiotherapy Journal (ACPRC, 1994) and staff involved in both the organisation and provision of emergency services were asked to respond. The response to the audit was poor, with a total of 52 responses from all members. Lack of information identifying respondents meant that repetition of information from individual units could not be excluded. This poor ill-defined sample did not allow for any meaningful statistical analysis. Recommendations from this initial survey were to redesign the audit tool and re-audit a sample of senior respiratory staff. This audit undertook to fulfil these recommendations, focusing on the support, education and training recommendations of the standards; thus standard 9 and its associated criteria formed the basis of this audit. Other than the previous Association of Chartered Physiotherapists in Respiratory Care audit (Brown et al, 1997), to the authors’ knowledge only three published studies have investigated on-call practice, provision and efficacy. Ntoumenopoulos and Greenwood (1991) documented the
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ACPRC Standard 9: All patients requiring emergency physiotherapy out of normal working hours receive safe and effective treatment Criteria 1. There is evidence of an agreed written emergency protocol. The protocol may include: Method of referral Expected response time Organisational details – recording system, security, bleep system, travel arrangements, accommodation and reimbursement system. 2. There is an induction programme for all staff participating in the emergency duty rota. 3. All participating staff are trained to an appropriate agreed level in accordance with local requirements. Aspects requiring specific training may include: Assessment of the acutely ill patient Physiotherapy skills relating to respiratory care Use of respiratory equipment available Pain management Endotracheal suction Physiotherapy management of the ventilated patient 4. There is evidence of ongoing training for all staff participating in the provision of an emergency service. 5. There is experienced specialist support available for staff. 6. There is documentation of service use. Documentation may include: Appropriateness Response time Referral source – profession and specialty 7. The service is monitored in accordance with local requirements. 8. There is evidence of the follow-up of inappropriate use of services.
Box 1
hours of provision of cardiothoracic physiotherapy services across Australia and how these services were organised. An incidental sample of hospitals with intensive care units was used to investigate the variance of 24-hour physiotherapy provision. Findings indicated a wide variability in service with 43% (n = 18) providing only normal working hours cover. This study looked solely at service provision and did not investigate explanatory, causal or practice issues. Jones et al (1992) further investigated chest physiotherapy practice in intensive care units in hospitals throughout Australia, the United Kingdom and Hong Kong. Provision of 24-hour on-call physiotherapy services varied between Physiotherapy February 2003/vol 89/no 2
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countries with 97% (UK), 49% (Australia) and 0% (Hong Kong) responders providing these services. A regular after-hours service was provided in 16% (UK), 41% (Australian) and 6% (Hong Kong) units. This study did not focus exclusively on oncall provision; it looked at numerous aspects of chest physiotherapy in intensive care units. It used small sample numbers in each country, with responders returning questionnaires per intensive care unit rather than per hospital. The questionnaire structure varied between countries making comparability of data incomplete in some cases. It made no attempt to investigate on-call provision in detail and did not consider on-call practice or procedures. More recently Ntoumenopoulos and Greenwood (1996) investigated the pro-
Section 1: Emergency duty protocol Q1 Does your department provide an emergency duty protocol for staff participating in the on-call rota? Yes – Please go to Q2 No – Please go to section 3 Q2 Which of the following statements best describes the emergency duty protocol within your department? There is an emergency duty protocol that is explained verbally to staff, but it is not documented in the written form There is a written emergency duty protocol clearly documented within your department Please state type of protocol if none of above are applicable
Q3 Which of the following areas are covered within your emergency duty protocol? Guidelines regarding expected response time following referral Documentation of patient assessment and treatment Security arrangements for the on-call physiotherapist The contact system, eg bleep or phone Necessary travel arrangements, eg hospital taxi service Accommodation arrangements whilst on-call Any remuneration / reimbursement system Information regarding available equipment A plan of the hospital Please state any other areas covered within the emergency duty protocol
Box 2: Examples of questions from the audit tool Physiotherapy February 2003/vol 89/no 2
vision of additional evening physiotherapy for post-operative pulmonary complications and intrapulmonary shunt (ventilation-perfusion mismatch) after abdominal surgery. Thirty-one elderly patients received either daytime only or daytime plus evening physiotherapy for up to 48 hours. Physiotherapy included combinations of positioning, gravityassisted drainage, breathing exercises, manual techniques, coughing and airway suctioning. Measurements (over 48 hours) included intrapulmonary shunt and incidence of post-operative pulmonary complications. The authors suggested additional evening physiotherapy might reduce post-operative deterioration in gas exchange after major abdominal surgery but that the effects of the individual physiotherapy techniques utilised were unclear. While this study went some way to analysing the effect of additional evening physiotherapy on short-term variables it did not address longer-term outcomes such as effect on length of stay in intensive care units or hospitals. The paucity of evidence in the provision, practice and effectiveness of emergency on-call physiotherapy duties requires attention and this audit was developed in an attempt to determine a baseline description of service provision, practice and adherence to national standards from which research investigating causation may be developed. The aims of this audit were therefore: 1. To audit current practice in the delivery of an emergency on-call service in one National Health Service Executive region against the Association of Chartered Physiotherapists in Respiratory Care standard 9 and its associated criteria. 2. To ascertain what support, education and training are currently provided for qualified physiotherapists in one Regional Health Authority before they take part in an on-call rota. Method Design and Implementation An audit of 20 hospital physiotherapy departments in the NHS Executive Trent Region was undertaken using a postal questionnaire to elicit information on emergency duty service provision, support and education for qualified physio-
Audit
therapists. Geographical location, ease of implementation, resource limitations and potentially faster response times were important considerations in deciding upon the audit tool. Standard 9 of the Association of Chartered Physiotherapists in Respiratory Care Standards for Respiratory Care was used as the basis for the audit. There is currently no nationally developed and validated tool available to audit these standards and thus the authors developed their own in the form of a postal questionnaire. This contained 21 questions with sub-sections relating directly to the criteria documented in standard 9. Examples of questions asked can be seen in box 2. For ease of completion and analysis, where possible a majority of closed questions were used to achieve a direct measure against the criteria (see question 1). Filtering was used to ascertain further details where necessary but exclude responses to inappropriate questions for others (see question 1). Additional information was collected via supplementary open-ended questions (see questions 2 and 3). The audit was distributed by post with a stamped addressed envelope to maximise response rate and on yellow paper to make it easier to read (Chesson, 1993). A covering letter was included to explain the purpose of the audit, identify the researcher and assure confidentiality. A number on the last sheet assisted with following up late responses and coded each questionnaire. Confidentiality was assured. Twenty-eight days were allowed for questionnaire completion and 15 were returned by the requested date, with a further three being returned following postal written reminders. Responses were available only to the authors and kept in a locked cabinet. At the time the project was undertaken, it was not obligatory to obtain permission from an NHS research ethics committee to question NHS staff. The proposal was approved through the approval process then in force in the university for undergraduate physiotherapy projects which took account of ethical issues such as the sensitivity of questions and the security of data as well as an assessment of risk. Sample There is little guidance on an appropriate sample size for audit purposes as the results will not be generalisable to other
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subjects. It seems that large numbers are not essential, between 20 and 100 usually being adequate (Buttery, 1998). The sample should be large enough to be confident that the obser ved level of compliance and any associated problems provide a reasonable reflection of reality. Twenty large acute trust hospitals from within the NHSE Trent Region were selected. All were between 500 and 1,000 beds, had physiotherapy departments, were teaching hospitals and had intensive care units. Senior I physiotherapists specialising in the field of acute respiratory care were invited to participate in the audit. Subjects were not selected randomly but formed a convenience sample from the target population. A pilot study was undertaken on two representatives of the target subject group at NHS hospital trusts outside the target region. The purpose of the pilot study was to identify any anticipated problems with ambiguity of instructions or questions. Comments on questionnaire design, content and problems with completion were sought. Minor changes to the layout and grammar were made. Data Analysis All raw data collected were of the nominal/ordinal level. Results were analysed and presented using a variety of descriptive statistical methods. Data analysis was done by hand owing to the small sample size. Results The results are presented in sections, each section representing a sub-section within the questionnaire. Response Rate Twenty questionnaires were distributed, and 18 were returned. This high response rate indicates excellent compliance and some reduction in bias of the sample (Oppenheim, 1992). Three were completed by superintendent physiotherapists and the remaining 15 by senior physiotherapists. Seventeen of the respondents were personally involved in preparing staff for participation in the on-call rota. Sixteen respondents were aware of the Association of Chartered Physiotherapists in Respiratory Care Standards for Respiratory Care.
Authors Tracy Dixon MSc MCSP is a senior physiotherapist in Westcotes Health Centre, Leicester. This article was written as part of her BSc honours degree, undertaken at Sheffield Hallam University. Julie Reeve MSc GradDipPhys is currently a senior lecturer in physiotherapy at Auckland University of Technology. She kindly provided supervisory and editorial support in her position of senior lecturer at Sheffield Hallam University from which she is currently on leave of absence. This article was received on April 19, 2001, and accepted on May 27, 2002. Address for Correspondence Tracy Dixon BSc MCSP, Senior Physiotherapist, Charnwood and Northwest Leicester Healthcare Trust, Westcotes Health Centre, Fosse Road South, Leicester LE3 0LP.
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General Information All respondents provided a physiotherapy service out of normal working hours (assumed to be from 8.30 am to 4.30 pm). This service took the form of an emergency call-out rota (referral by phone or bleep) in all departments, with six respondents offering no further means of service. Other types of emergency service provision can be seen in figure 1. Staff grades were required to participate in on-call duties in 17 hospitals. In three hospitals the only staff to undertake oncall duties were those who had completed a rotation or specialised in respiratory care. Four respondents did not use senior I physiotherapists as part of the on-call rota. One respondent used all staff and senior II physiotherapists but used senior I physiotherapists only if they specialised in respiratory care. Figure 2 illustrates at what stage physiotherapists were expected to undertake on-call duties. One respondent expected all new staff, regardless of grade and experience, to participate in on-call immediately following employment, but provided a training programme to support this.
Shift work
Planned call-out rota
Emergency call-out rota
0
5
10
15
20
Number of respondents
Fig 1: Type of emergency service available
Number of respondents
12 10 8 6 4 2 0 Specialist training
Immediately
After one rotation
Fig 2: Stage of staff physiotherapist participation in on rota call
Focus group
Senior I
Superintendent
0
2
4
6
8
10
12
Number of respondents
Fig 3: Responsibility for establishment of emergency duty protocol
Plan of hospital Available equipment Accommodation Security arrangements Response time following referral Reimbursement system
Section 1: Emergency duty protocols All respondents said they had an emergency duty protocol for physiotherapists participating in the on-call rota. Sixteen respondents had a documented protocol and one had an emergency duty protocol that was orally explained but not documented in writing. Figure 3 represents the grade of physiotherapist responsible for the establishment of the emergency duty protocol. Figure 4 highlights areas suggested by the Association of Chartered Physiotherapists in Respiratory Care to be covered within the emergency duty protocol and the percentage of hospitals adhering to these. Six respondents had all ten suggested areas covered within their protocol.
Travel arrangements Contact system Documentation of assessment and treatment Method of patient referral 0
10
20
Number of respondents
Fig 4: Areas covered within the emergency duty protocol
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Section 2: Induction programme before on-call duties All respondents reported a form of induction training programme available to physiotherapists. A formally organised induction programme, which all must attend before participating in emergency duties, was available in 14 hospitals with
Audit
Section 3: Level of training Agreed standards of practice for physiotherapists before participation in emergency duties were present in 11 hospitals. One respondent was in the process of reviewing practice and developing such standards. The remaining
12
10 Number of respondents
four hospitals providing training on an informal basis. Ten respondents covered all aspects recommended by the Association of Chartered Physiotherapists in Respiratory Care for inclusion in induction programmes. Reasons for non-adherence to suggested areas were not stated. Aspects other than those suggested by the Association of Chartered Physiotherapists in Respiratory Care included paediatric respiratory care (n = 3), specific medical conditions or pathologies (n = 2), cardiothoracic surgery and tracheostomy management (n = 1). Induction programmes involved the direct input of senior I respiratory clinicians in all hospitals. Nine respondents indicated senior I physiotherapists had sole responsibility for induction training. Seventeen hospitals offered some form of induction programme before expecting physiotherapists to participate in the on-call rota. Figure 5 illustrates those for whom respondents considered it necessary to undertake an induction programme. Additional responses included bank staff (n = 1), those returning to work following career breaks (n = 1) and senior clinicians working in other clinical areas (n = 4) to require induction training also. Length of time given to the induction programmes varied between respondents. Seven respondents provided induction training lasting from one to five working days. The option of completing one full rotation in respiratory care was available in some departments if this duration was subsequently found to be insufficient. Three respondents stated the induction duration for new staff before on-call duties depended purely on their past experience, knowledge and confidence. Six respondents indicated a period of more than five days induction training – the structure of this varied from two weeks based on an intensive care unit to eight weeks of lectures on an impromptu basis but including five days gaining practical experience.
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8
6
4
2
0 All new staff
Limited respiratory experience
Staff grades only
Fig 5: Staff receiving on-call induction
six hospitals had no agreed standards in place. Of those with agreed standards, formal assessment of achievement of these standards was poor. The majority of respondents used informal, subjective methods to measure competence including senior physiotherapist satisfaction, peer assessment by others in the induction group, and self-assessment. One respondent used a knowledge quiz. Competence was mainly assessed by senior I physiotherapists (n = 15). Section 4: On-going training All respondents stated some form of ongoing training in emergency duties was available for physiotherapists within their departments. The majority of departments (n = 11) implemented an optional ongoing training programme with resources available for continuing professional development opportunities. Training for physiotherapists in the form of a compulsory in-service training programme took place in seven hospitals. One respondent failed to answer the question. Ongoing training in emergency respiratory care occurred annually (n = 2), biannually (n = 4), monthly (n = 6) or weekly (n = 2). Four respondents provided training on request only and five units provided training on request in addition to their more formal ongoing training programmes. In 16 units, senior I respiratory therapists were responsible for ongoing training of staff participating in emergency on-call duties. Physiotherapy February 2003/vol 89/no 2
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Overall Compliance Key questions in each section of the questionnaire were used to ascertain overall compliance to Association of Chartered Physiotherapists in Respiratory Care criteria, summarised in figure 7.
12
Number of respondents
10 8 6 4 2 0 All senior staff by phone
All senior respiratory staff by phone
Senior respiratory staff by phone or in person
Fig 6: Types of support available while on call
Experienced support available Agreed level of training Service monitored Documented protocol On-going training Induction 0
5
10 15 Number of respondents
20
Fig 7: General compliance with ACPRC standards
Section 5: Support available while on-call All respondents stated that some form of support was provided to physiotherapists during emergency duties. Figure 6 indicates the type of support available. Two respondents stated a senior physiotherapist would always work at weekends as back-up if an inexperienced member of staff was nominated as first-line cover. Sections 6 and 7: Documentation and monitoring of service Fifteen respondents monitored the emergency on-call service provided by their department in some way. Areas documented by respondents included patient assessment and treatment (n = 13), inappropriate call-outs (n = 3) and on-call response times (n = 3). Recipients’ evaluation of on-call training (n = 7), adherence to the emergency duty protocol (n = 10) and practice while actually on call (n = 10) were monitored. No hospital monitored the referrer satisfaction with the on-call ser vice provided. Other areas monitored included on-call usage trends, use of on-call rooms, workload on-call and cost (n = 1). Physiotherapy February 2003/vol 89/no 2
Discussion Where standards exist, compliance with them should be monitored and this forms an intrinsic part of the audit cycle. Monitoring should provide objective measures of how successfully the standard has been implemented in everyday clinical practice, identify reasons for any non-compliance or variance, and inform decisions about how to increase compliance (Buttery, 1998). Guidelines (standards and protocols – terms often being used interchangeably) provide evidence about expected practice and may be used in litigation proceedings, but compliance with guidelines does not defend against liability where these are inappropriately applied (Mead, 1998). Any non-compliance warrants further investigation but should be examined while considering applicability to local situations or individual patients. Practitioners have a responsibility to be aware of the existence of guidelines/standards/protocols and to make value judgements as to the applicability of these locally. This audit examined the local implementation of national standards but did not attempt to address the quality of the ser vice provision. Association of Chartered Physiotherapists in Respiratory Care standard 9 states that all patients requiring emergency physiotherapy out of normal working hours should receive safe and effective treatment. The associated criteria essentially reflect broad statements of service provision rather than considering the safety and effectiveness of interventions. While respondents may adhere to these broad standards, actual practice may vary and this should be audited in the future. Other forms of audit such as observation of practice, peer review, self-assessment and review of induction and training programmes should be undertaken. Physiotherapists’ rules of professional conduct (CSP, 1996) state that chartered physiotherapists shall practise only to the extent that they have established and maintained their ability to work safely and competently. The
Audit
responsibility for this within the on-call environment lies initially with physiotherapists but it requires provider units to monitor competency to practise and ensure service needs are met. Clearly identification of the quality of the service provision needs closer attention in future research. Despite a small sample size, a questionnaire response rate of 90% (n = 18) is considered good (Babbie, 1973) and suggests that the sample is representative of the target population studied. It may be suggested that the high response rate reflects the importance of this topic to the subject group, making it possible to identify general trends, educational opportunities, and variance in service provision within the target population. These results should not be extrapolated to the wider population and it is recommended that this audit should be replicated at a national level. The majority of our respondents were responsible for the training and support offered in preparing staff grades for participation in the on-call rota. This is a potential source of bias. As our study’s main aims sought a description of ser vice provision and adherence to standards, it was felt that senior cardio-respiratory clinicians were in the most appropriate position to provide the information. Future studies focusing on the quality of the service provided should seek wider views, including those from physio-therapists receiving training, those requesting oncall services, and patients. The results of our audit identify similar findings to those of the previous Association of Chartered Physiotherapists in Respiratory Care audit in 1996. It extended this by addressing not only which standards were being adhered to but also the underpinning practice used in implementation of the standards. It also examined the type and amount of support and training provided. This information has not been previously sought. Emergency Duty Protocols It is believed hospitals using therapistdriven protocols enhance practitioners’ per formance (Meredith et al, 1994). Written protocols should help provide a safe framework for basic practice, enabling clinicians to make clinical decisions within the scope of their own
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knowledge and experience. Our audit indicated that the emergency duty protocols in the sample studied offer guidance on service provision rather than guidance on patient care which would help clinicians in making decisions about appropriate treatments for specific conditions. Clinical guidelines provide recommendations for specific clinical inter ventions which have been systematically developed (Mann, 1996). Having clinical guidelines in place should help inexperienced physiotherapists in clinical decision-making. Professional groups should be working towards the development of these. Induction Programmes Reasons for the variance in the frequency, length, and content of training programmes between provider units, including the impact of these variations, require further investigation. Mead (1999) believes it is difficult to ensure the local use of specific national guidelines and it is therefore accepted that national standards may need adaptation to the local context where scope of practice, resources required and mode of practice will vary according to local conditions and demands. Our results demonstrated local variations and may show that inappropriate areas of practice are suggested within the Association of Chartered Physiotherapists in Respiratory Care standards or indicate that resources available (eg staff and time) for formal training in all suggested areas are impractical. Agreed Standards of Practice While determining whether respondents had agreed standards of practice before participation in emergency duties, our audit did not ascertain the variability or content of these standards between responders. However, the number of departments using formal methods to assess standards was disappointing. Achieving agreed standards before on-call duties should ensure safe, effective levels of practice. Competency-based testing may be one means of assessing standards in order to meet local requirements but this must include clinical decision-making and problem-solving strategies. Our results may highlight some of the conflicts and difficulties of assessing competency to practise in staff who may be recently Physiotherapy February 2003/vol 89/no 2
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designated fit to practise or professionally registered or have previous experience. The Chartered Society of Physiotherapy’s first rule of professional conduct (CSP, 1996) describes physiotherapists’ responsibility to maintain their competence to practise. With the clinical governance initiatives implemented from April 1999, physiotherapists, educators and managers must take increasingly seriously the need to demonstrate this competence. One of the key components of clinical governance is to ensure that those providing care are appropriately trained and have the skills and competencies required to deliver the care needed. These initiatives may enable compulsory regional or national programmes to be developed to ensure maintenance of a contemporary knowledge base, and address the difficulties inherent in assessment of competency. Clinical Interest Groups may need to consider their role in the development and implementation of nationally agreed standards in the future. Departments need to ensure that key advances, changes in practice and maintenance of professional skills are addressed by ongoing training and development programmes. Strategies for dealing with staff not reaching agreed standards were not sought in this audit but would provide valuable information for development of future guidelines. Specialist Support The fact that many respondents offered support for physiotherapists carrying out emergency duties demonstrates clear recognition of the stressful and specialist nature of the work and the necessity to provide on-the-spot support for less experienced staff. The level of take-up of this support was not investigated but may prove useful in further work. Documentation and Monitoring of Service Provision Areas monitored proved widespread but variable. Given current quality of care initiatives it is surprising that no respondent monitored referrer satisfaction. Procedural difficulties in referral,
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appropriateness of referral and satisfaction with the outcome of referral must be considered in the delivery of an emergency service from both consumers’ and providers’ perspectives. Monitoring of inappropriate use of on-call services and strategies for dealing with these require further investigation. These aspects of service provision should be key areas for audit given the current pressures on healthcare resources. Documentation of physiotherapy call-outs should be considered fundamental for audit, research and legal purposes. Conclusion This audit has demonstrated differing levels of support, education and training for physiotherapists before participation in emergency duties. This consists of an induction programme in all units, guidance in the form of written protocols, regular in-service training and, in the majority of departments, senior support while on-call. It has also shown that all junior physiotherapists working within the Trent Region are expected to participate in the delivery of an emergency respiratory care service. It has shown current practice in the delivery of an emergency physiotherapy service in the Trent region to be broadly in agreement with standards for emergency duty care suggested by the Association of Chartered Physiotherapists in Respiratory Care, but that compliance with individual criteria is inconsistent throughout the chosen sample. This variability indicates the necessity for review and development of more specific guidelines. Clinical Interest Groups should be involved in the further development of these. Key future work needs to widen the sample audited in this study. It should address the quality of practice as well as service provision and examine whether Association of Chartered Physiotherapists in Respiratory Care standards of practice are adequate for the needs of patients, physiotherapists and other health care providers. Audit of other Association of Chartered Physiotherapists in Respiratory Care standards should also be undertaken.
Audit
References Association of Chartered Physiotherapists in Respiratory Care (1994). ‘Emergency duty audit’, Physiotherapy, 80, 9, 621-622. Association of Chartered Physiotherapists in Respiratory Care (1996). Standards for Respiratory Care, ACPRC, London. Babbie, E R (1973). Survey Research Methods, Wadsworth, California, pages 159-170. Brown, A, Hinton, F and McMullin, E (1997). ‘Emergency duty audit by the ACPRC’, Journal of the Association of Chartered Physiotherapists in Respiratory Care, 30, 33-34. Bury, T and Mead, J (1998). Evidence-based Healthcare, Butterworth Heinemann, Oxford. Buttery, Y (1998). ‘Implementing evidence through clinical audit’ in: Bury, T and Mead, J (eds) op cit, chap 9, pages 182-207. Chartered Society of Physiotherapy (1996). Rules of Professional Conduct, CSP, London. Chartered Society of Physiotherapy (1999). ‘Annual Representative Conference motion 23’, Physiotherapy Frontline, 5, 6, 18. Chesson, R (1993). ‘How to design a questionnaire’, Physiotherapy, 79, 10, 711-713. Healthcare Quality Quest (1997). ‘Getting audit right to benefit patients’, HQQ. Jones, A Y M, Hutchinson, R C and Oh, T E (1992). ‘Chest physiotherapy in intensive care units in Australia, the UK and Hong Kong’, Physiotherapy Theory and Practice, 8, 39-47.
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Mann, T (1996). Clinical Guidelines: Using clinical guidelines to improve patient care within the NHS, Department of Health, London. Mead, J (1998). ‘Developing, disseminating and implementing clinical guidelines’ in: Bury, T and Mead, J (eds) op cit, chap 8, pages 162-181. Meredith, R L, Pilbeam S P and Stoller, J K (1994). ‘Is our educational system adequately preparing respiratory care practitioners for therapist-driven protocols?’ Respiratory Care, 39, 7, 709-711 Mottram, E and Flin, R H (1988). ‘Stress in newly qualified physiotherapists’, Physiotherapy, 74, 12, 607-612. NHS Executive (1996). Clinical Audit in the NHS. Using clinical audit in the NHS: A position statement, Department of Health, London. Ntoumenopoulus, G and Greenwood, K M (1991). ‘Variation in provision of cardiothoracic physiotherapy in Australian hospitals’, Australian Journal of Physiotherapy, 37, 29-36. Ntoumenopoulos. G and Greenwood, K M (1996). ‘Effects of cardiothoracic physiotherapy on intrapulmonary shunt in abdominal surgical patients’, Australian Journal of Physiotherapy, 42, 297-303. Oppenheim, A N (1992). Questionnaire Design, Interviewing and Attitude Measurement, Pinter Publishers, London.
Key Messages ■ Junior physiotherapists are expected to participate in the delivery of an emergency physiotherapy service. ■ Support, education and training for physiotherapists before participation in emergency duties is variable.
■ Variability in support, education and training provided indicates the necessity for review and development of more specific guidelines. ■ Quality of practice as well as service provision needs to be reviewed.
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