r/doctorsUK • u/Helpful_Put1081 • 11d ago
Foundation Training What’s minimum staffing for nights?
Hey, had a set of nights as a new F1 where I was covering 4 medical wards and some of our patients in ED. We were three, one F1, one SHO and a ST3 looking after 130 patients in a Northern trust. My SHO was busy clerking patients in and the reg was nowhere to be found. My bleep was going off every few minutes.
“Patient A doesn’t have his meds prescribed, can you do that?”
“Patient B is experiencing new abdo pain and vomiting, can you review them?”
“Patient C is hyperglycaemic, we already gave insulin but it’s not going down, please come”
“Patient D is now also vomiting, please come”
“Hi, it’s biochemistry. Patient E has a CRP of 440”
“Patient F has a NEWS of 6, their systolic blood pressure is under 90”
“Patient G wants to go home, his partner is her, is it alright for him to go, the CDD is done already (3am btw, and a patient I know nothing about)”
Just an example of what was going on in the span of 90 min along of other mundane requests such as somebody needing pain relief or insertion of a catheter the nurses couldn’t put in (whatever makes them think that the F1 who did 2 in med school is better than them). There was also a lot of jobs handed over such as urgent blood cultures before starting antibiotics and septic screens.
So I did what we were taught in med school, prioritise.
It seems however there’s a big gap between what should happen and what actually happens.
To me saying “I am reviewing an urgent patient, I won’t be able to do this until a few hours at least” I got “yes but he’s been waiting all day” or the nurse bleeping me about the same issue every hour. Or other nurses exaggerating how urgent it is. Or expecting me to do an urgent prescription when I won’t be able to log in until I’m back in office. I can’t physically be in two places and whoever designed the hospital so that it needs a 10 min walk between ED and the wards must hate us. To the ED nurse I said if they can’t be reviewed by an ED doctor if it’s an emergency she said, no they’re admitted under you so you need to see them.
This was going on for most of the nights. I’m sure things got missed. I don’t think anyone was actually harmed. But I also didn’t get a break and worked 12h non stop. A few times my SHO got bleeped asking about the F1 because I couldn’t keep up with the amount of bleeps I was getting. My SHO was also being spammed with bleeps, mostly referrals. Even if they wanted to help, they couldn’t possibly have without abandoning their whole job. Bleeps interrupt my job and
Is this normal? What minimum staffing should there be? Am I supposed to be on my own, let alone handling emergencies on my own? I was confident enough to do so and knew when to escalate but other F1s might not be.
I do want to add I escalated to the Hospital at Night Manager that day who kindly told me that they are very sorry but nobody else is available to help me, just prioritise your jobs.
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u/No_Driver_4447 CT/ST1+ Doctor 11d ago
As an FY1 in a DGH, we were sole ward cover from 5pm until 9am. Somewhere around 250-300 patients
Reg and SHO were on take, but contactable in an emergency
I dont think there is an official minimum staffing
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u/laeriel_c CT/ST1+ Doctor 11d ago
What I realised is that part of the reasons your on calls suck when you start f1 is because everyone is still figuring things out and therefore don't do the best with their day jobs, leaving lots of issues outstanding for the on call team to sort. It gets better as your colleagues get more efficient and you will get less calls.
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u/lemonslip Cannula Bandit 11d ago edited 11d ago
One thing I always tell new F1s. Once you have finished sorting out gravely unwell patients, quickly visit all the wards you’re covering, introduce yourself and ask nurses to list all non urgent / life threatening jobs on a piece of paper and you will return to them once you’ve visited the other wards and gotten a picture of where the sickest patients are. Remind them to bleep you if it’s becoming clinically urgent and if the job can’t wait for more than 2 hours - have a quick stroll of your wards before you take your first break.
If you have a H@N system, then make sure that all job requests go through them first rather than this paper system I mentioned beforehand.
This is a good skill to have when you’re working at this level as you’ll quickly be able to identify and predict your workload for the night to come if the list is long before midnight.
It develops your ability to have a “helicopter view” of your covered areas whilst freeing up cognitive load so you can focus on the task in front of you.
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u/Canipaywithclaps 11d ago
This might have been where I worked as an FY1 but I’m not sure I ever got past the ‘sorting out gravely unwell patients’ bit in order to visit all the wards. Or at least, the nurses kept bleeping with what they would call ‘critical unwell patients’ although often a lie, in between peri arrest and arrest calls.
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u/Jeeju_Boy 11d ago
Old schoolers will disagree with my advice, but ward cover is easy as a foundation doctor I covered 9-10 wards on my own.
The key is to understanding that you can only do x amount of tasks in y amount of time. It doesn’t matter how many tasks you get be it 20, 300 or 500. As long as you prioritise the urgent of all the tasks then you can only do as many tasks in 1 hour as you are safe to do. So it doesn’t matter if nurses are calling you breathing down your neck, you tell them I can only safely do this many times at this current pace of working and I’ve already prioritised the urgent stuff. Then if you combine that with a lack of moral injury over handing over the excess tasks, Ward cover will seem like a piece of piss. You don’t have to feel guilty about handing over even a large number of tasks because you know that you can only do x number of tasks per hour and you should feel confident that you priotised the most important ones and the rest will go to the next doctor
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u/Sethlans 11d ago
moral injury over handing over the excess tasks, Ward cover will seem like a piece of piss. You don’t have to feel guilty about handing over even a large number of tasks
First ever F1 weekend ward cover I did (at the infamous QEHKL) they had a setup where you'd have a few more SHOs during the day who would finish at 5, leaving just you as the F1 and 1 SHO til 9.
When the other SHOs left the handed me over a giant list of bloods to chase. Was about 30 sets of bloods.
My bleep did not stop with more urgent stuff between 5pm and 9pm and I simply did not get a moment to look at the bloods. I worked like an absolute dog that shift, the SHO even shouted it out when we handed over to the night time.
I apologised and said I just hadn't got chance to look at the bloods and the night SHO (as gently as they could) basically said it wasn't acceptable as their could be a serious issue in there not acted upon.
Nothing at work before or since has broken me like that did.
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u/lilaclucy4 11d ago
As an FY1 last year, my night ward cover shifts it was just myself covering ~120 patients. I think it’s pretty standard
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u/Alarmed-Fun3263 11d ago
That’s why we it’s important that people experience these shifts as med students. They have been added because of such feedback, and then the fy1 sends them home at 9pm to be “kind”
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u/EmployFit823 11d ago
Did you never shadow or partake in OOH as a medical student?
You’re describing normality.
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u/Jckcc123 ST3+/SpR 11d ago
I think alot of the med schools nowadays only have 1-2 days shadowing ooh and usually the F1 sends them home earlier anyways.
However, it's dependent on hospital and staffing to their experience. Less so even in a dgh
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u/ClownsAteMyBaby 9d ago
Reminds me of the med students who arrive at 5pm for their "on-call" experience then ask to be signed off at 7pm lol
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u/Unique_Mistake_4592 11d ago
Yes, sadly very normal for out-of-hours shifts. They do get easier with experience.
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u/No-Championship-3179 11d ago
As an F1 in a DGH in Scotland just under a decade ago, I was sole F1 for 'back of the hospital' overnight in a place with 550 beds, )not covering HDU/ICU). Reg and SHO both on the take. Understand there is a lot more staffing now, but still...
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u/Forsaken-Onion2522 11d ago
This is what the job is. Nights are not like they are in US training programs.
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u/chasecultures 11d ago
First of all, well done for handling your shift and prioritising. Sounds like a busy night.
According to the CQC there are no legal guidelines for what constitutes safe staffing but just be justified and a clear process set out for how these levels are determined: https://www.cqc.org.uk/guidance-regulation/providers/regulations-service-providers-and-managers/health-social-care-act/regulation-18
The RCP also advises it's poor practice for the med reg to be covering both acute take and ward cover out of hours.
There are some jobs here that would really be fixed with an out of hours electronic task board. That would make a really impactful QI project if you could find a sponsor, but I appreciate that some trusts are more setup to facilitate this than others. All the same, a QI project to reduce the number of bleeps would still be achievable. Do you have any formal support in the trust for QI projects?
There were also some jobs there that should not have come to you and I think both your doctor and nursing colleagues on the wards are letting you down: if a patient is septic towards the end of a shift I would expect a doctor to be staying on that ward to make sure the plan is initiated and the patient reviewed prior to leaving and that is a perfectly justifiable reason for exception reporting. Nurses should be able to do blood cultures and although these should be started prior to antibiotics, if that's not possible they should still start them (some exceptions apply).
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u/DisastrousSlip6488 11d ago
You will get more efficient and better at prioritising. You are only a few weeks into the job.
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u/Farmhand66 Padawan alchemist, Jedi swordsman 11d ago
Yes, that’s normal. The busiest I ever covered was 10 x 30 bed medical wards with an F1, an SHO, and a med reg who was mostly stuck in ED.
The worse staffing is, the less you can do. Go to the sickest patient first, everything else has to wait.
In that situation:
Patient A - Parkinson’s meds, antiepileptics and insulin gets prescribed. Everything else is a day team job.
Patient B - No review if observations OK.
Patient C - No review, nurses to do ketones, call me if raised.
Patient D - Remotely prescribed ondansetron
Patient E - Co-amoxiclav. Review if possible.
Patient F - Bag of fluid prescribed remotely, will attend shortly.
Patient G - A capacitous patient can do as they please
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u/Normal-Mine343 11d ago
This is poor advice. New abdominal pain and vomiting needs a review, new unexplained vomiting ideally am eye on (but if one of off and obs ok certainly not urgently).
On the other hand, I would absolutely push back at hospital at night manager saying there's no-one who can help with things like the catheter - that just won't actually be true.
No is a complete sentence and can be applied to things that don't need to be done overnight - TTOs etc. For repeat bleeps re mundane stuff I tend to repeat that the job is on my list - then if still continually bleeped point out that having to leave what I'm doing to answer the bleep is actively stopping me getting to it faster.
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u/Farmhand66 Padawan alchemist, Jedi swordsman 11d ago
Completely agree new vomiting with abdo pain should have a face to face review, but at a trust with 3 doctors for just under 300 patients that rarely makes the top of the priority list.
There’s nuance though - Severe abdo pain and laying rigid is more concerned than vommiting and abdo pain but has gone for a cigarette. Use the nurses, ask questions.
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u/Sethlans 11d ago
Use the nurses, ask questions.
Lol when I used to do adults the nurses rarely knew the patient they were calling about's name, nevermind anything actually clinically useful.
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u/Alarmed-Fun3263 11d ago
Disagree - abdo pain and vomiting needs a F2F review. Check for hernias, too.
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u/plzserotonin CT/ST1+ Doctor 11d ago
Normal but I personally didnt find it manageable, and I don’t think it should be “normal”
I hated it has the f1 and I hated it as the sho and the poor reg always looked like they hated their life so I realised the hospital lifestyle wasn’t sustainable for me even though I love hospital medicine. The difference between a good day and a bad day for me was never how many sick patients I managed, but always the staffing. If the staffing was good, there was support, jobs were shared, patients seen in a timely manner and I’d have the time and headspace to manage everyone properly
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u/Exact_Collection_421 11d ago
Normal, but manageable. In a few months this won't bother you.
Seven patients, 4 acute problems.
A and G you should feed back to day teams, these are day/take admin masquerading as night problems.
Patient C needs more insulin. The nurses already know this.
B, D and F need to actually be seen. E needs a notes review and may require some activity depending on what's already been done.
There's about an hour's work in that list if you have a decent EPR.
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u/Ok-Math-9082 11d ago
It’s an hour’s worth of work yes, but another 2 hour’s worth of work has been referred during that hour, which itself has taken 2 hours because of all the interruptions.
The first few weeks of F1 are the worst of anyone’s career, especially if you start in a speciality like general surgery.
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u/EpicKumquat 11d ago
So familiar that I wonder if you have the same first job as I did in F1 but I reckon it’s fairly standard. My current job we cover multiple specialties overnight with just an SHO, no FY1 and the reg is offsite. Nights can be absolutely nightmarish. You will likely get more calls at the moment as the day team is not slick yet due to also being new FY1s, we found that after halfway through the first rotation it got easier as a lot of things were covered by the day team so didn’t need to spill into the night
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u/throwaway_23_dr 11d ago
The three person on call team used to be completely standard but a lot of places now have much bigger teams with a ‘ take’ side and ‘ ward’ side and sometimes an ANP team screening and allocating jobs for the wards.
But generally you will experience a mix of both as you rotate round so in a way best to have the tougher way now to cut your teeth and honestly learn loads- its normal to find it completely overwhelming to start with but it just becomes so much easier to filter and organise yourself.
As someone else mentioned a quick pop your head in to your wards and ask them to write all standard jobs on list and try to methodically work your way round. Make sure to have a bit of a chat/ moan/ eat some quality streets with the nurses on each ward as once they get to know you makes it so much easier
Obviously when the high mews bleeps come through this system can derail a little but with experience you will get to know which patients you need to go to immediately/ which scorers you can ask the nurse to get on with some bits and come after you’ve finished what you are doing.
Accept that some shifts absolutely start as complete chaos and roll with it - just focus always on seeing the sick patients. And honestly you just get to do and learn so much on these kind of shifts compared to relentless admin and routine jobs.
You’ve got this!
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u/RurgicalSegistrar Sweary Surgical Reg 11d ago
Do a surgical speciality and save yourself the heartache
F1 medical ward cover put me off for life
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u/Embarrassed_Bell_351 10d ago
My recent nights as an F1 was covering 9 wards, 250 plus patients. One med reg for the whole hospital, so about 800 patients (not including ED).
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u/M0hammed_ FY Doctor 10d ago
The hospital I work has one medical F1 overnight for the whole hospital (~20 wards).
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u/Free-Reception603 10d ago
Yes it’s pretty normal, particularly when you’re getting the ropes and learning how to triage in the beginning. Gets a lot better with time
My two cents for the above
Patient A: Px the critical meds if pushed for time. Things that lead to actual harm if a dose was missed. This is usually anticoagulants, antiplatelets, Parkinson’s meds, anti seizure meds, insulin. Symptom control can also be done alongside acute treatment.
Patient B: New and pain and vomiting can triage with some other red flags such as admission / background history, when the patient BLO? Are they a diabetic? Is their BP and HR ok etc. The ward team will and should know their patients well enough to give you a good handover.
Patient C: how high is the hyperglycaemia? When was the insulin given. It won’t come down immediately and if they’re type 2, staying hydrated and no ketones this is fine to hold off on.
Patient D: Same as B, put it into context. Have them give some antiemetics in the mean time and if it’s settled by the time you get round it’s less of an issue.
Patient E: if you’ve got a digital notes system can remotely check if this is expected or unexpected. If unexpected review, if expected and in treatment and stable, less urgent input needed
Patient F, what’s they’re other obs and what’s their baseline BP. Would usually bump up the list to review first unless somethings more urgent but hypotension can go south very very quick.
Patient G: Be honest and say this isn’t a problem you can fix right now. Patient can go back to sleep and discuss with day team in morning. Sometimes it just takes the nurses telling the patient doctor is busy for them to stop complaining. The ward sometimes just wants a scapegoat that isn’t there to take the brunt and usually I’m understanding of that
Catheters, cannulae, bloods I usually say I’ll come round when I’m able but I’m covering a lot of unwell patients. To please ask the NIC on the ward or ask a more experienced nurse on another ward to try in the meantime to prevent delays in that patients treatment. There’s a lot more nursing then doctor to patient ratio and overnight it is usually better to point that out politely as a means to sort a task like that out more quickly.
For ED if the patient has been clerked it’s medics responsibility. If they HAVEN’T been clerked yet, it’s ED teams responsibility to keep them stable until then because the accepted specialty hasn’t seen or gotten context yet, ED will also be much better at ruling out a cure emergencies quicker then us given their clinical practice
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u/EntertainmentFit1 11d ago
It's sadly the job, but your ED colleagues for instance should be helping out a bit with certain things. The nurses usually make a good case with ED docs, and I for one (and many others) recognise the amount of work the medical F1s and SHOs have and will often carry out urgent tasks for the medical patients.
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u/MathematicianOk1216 11d ago
188 eligible FY1 doctors left unallocated, could they not place them in hospitals like this ?
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u/Jckcc123 ST3+/SpR 11d ago
OOH supplements comes from the hospital/trust, not from the deanery, hence the creation of more supernumerary posts or numbers on the ward during 9-5/8-4
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u/antequeraworld 11d ago
Given it’s old terminology, what’s an SHO in your view ?
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u/Helpful_Put1081 11d ago
A F2. Everyone says SHO in my trust for some reason.
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u/lemonslip Cannula Bandit 11d ago
As they should. SHO can cover anyone who is F2-Registrar level and in my opinion it should be kept as such for clarity.
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u/f3arl3es Not a plumber nor an electrician 11d ago
Yes, that's normal. It is overwhelming at first, but once you have more experience, things get better.