Hospitals should re-think the provision of an after hours on call phone service for children and young people with type 1 diabetes because it is an unnecessary and unsustainable burden for endocrinology staff, a major NSW tertiary hospital has shown.
The Institute of Endocrinology and Diabetes, Children’s Hospital Westmead has successfully trialled an alternative model of care to the historic 24-hour phone services that provide clinicians support to families and other departments on issues such as hypoglycaemic episodes and sick day management.
By restricting the advice service to 8am to 8pm, the hospital was able to relieve much of the on-call burden for junior endocrinology staff without shifting management of diabetes into emergency departments or to other junior staff.
The hospital switched to a new model of care in 2017 because it was felt the traditional model of after hours on call services was unsustainable for understaffed endocrinology departments that are forced to rely on ‘soft’ funding from donors or research budgets to provide the services.
Before making the switch, the hospital provided additional education and support to the 750 patients with T1D and their families to empower them in self-care and diabetes trouble-shooting , with the aim of reducing dependency on hospital staff in the after hours period. Anecdotally it was noted that many of the calls to the after hours service were trivial or related to non-urgent issues. Non-endocrine junior medical officers (JMOs) were also upskilled in acute endocrine care.
The revised on-call system dropped the 24-h service for families, who were advised to present to the ED or call an ambulance if they were unable to self-manage their diabetes outside of the 8am-8pm time period. In-hospital calls were re-directed to on-duty hospital JMOs rather than directly to the endocrine JMO on-call from home.
Following the introduction of the new system the number of diabetes-related calls fell from nine to two per shift, and the number of shifts that had no calls increased from 2% to 24%.
For JMOs, the number of disturbed’ nights, fell from 75% to 29% and all reported that they had more sleep and better work-life balance as a result of the new system.
Importantly there was no increase in diabetes-related presentations to the hospitals ED in the seven months following the introduction of the new system and no significant changes in the proportion of calls relating to hyperglycaemia or hypoglycaemia or in the rate of diabetic ketoacidosis.
Writing in the Journal of Paediatrics and Child Health, the study authors led by Dr Andrew Biggin said a survey of 10 hospital endocrinology departments in Australia found that 70% believed their after hours service provision was unsustainable, and most were faced with workforce and funding problems.
They noted that IPSAD guidelines recommend hospital endocrinology provide 24-hour on call services for T1D patients, but said this model was unsupported by any evidence from evaluations.
“This study portrays an example of an entrenched, historical belief about the need for a type of medical service delivery, when there has been no objective analysis,” they wrote.
“Some stakeholders predicted negative medical outcomes and consumer complaint, which was proven not to be the case.”
They concluded that traditional 24-h on-call service models are unnecessary, and that with appropriate planning, organisation and patient training, changes to the model “can have positive implications for resource utilisation and junior medical officer well-being.”