Ir J Med Sci DOI 10.1007/s11845-014-1154-8
ORIGINAL ARTICLE
A prospective audit of emergency urology activity in a university teaching hospital E. J. Redmond • J. C. Forde • M. A. Abdelrahman N. P. Kelly • C. Akram • S. K. Giri • H. D. Flood
•
Received: 31 January 2014 / Accepted: 26 May 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Introduction Urology cover is commonly available outof-hours in most teaching hospitals. However, increased pressure to reduce hospital expenditure has forced many institutions to consider removing middle grade cover outside of normal working hours. The aim of this study was to audit the emergency urology activity in our institution over a 12-month period. Methods A prospective logbook was maintained for all urology referrals from the emergency department between August 2012 and March 2013. The diagnosis and patient outcome was recorded for each referral. The emergency theatre logbook was retrospectively evaluated for all emergency urology procedures carried out over the same time period. A basic cost analysis was performed to calculate the cost of providing the on-call service. Results A total of 752 patients were referred to the urology service over a 12-month period. The most common reasons for referral were renal colic and scrotal pain. Approximately 41 % of referrals were discharged directly from the emergency department. There were 167 emergency operations performed in total. The majority of emergency operations and referrals from the emergency department took place outside of normal working hours. A basic cost analysis revealed an associated cost saving of €58,120.
This work received the ISU Registrar’s Prize when presented at the Irish Society of Urology annual meeting in September 2013. E. J. Redmond (&) J. C. Forde M. A. Abdelrahman N. P. Kelly C. Akram S. K. Giri H. D. Flood Department of Urology, University Hospital Limerick, Dooradoyle, Limerick, Ireland e-mail: [email protected]
Conclusion Emergency urology activity constitutes a large proportion of the workload at our institution. Restricting emergency urology cover would limit essential training opportunities for urology trainees, increases length of stay and delay treatment of urological emergencies. Urology ‘‘out of hours’’ cover is a cost-efficient method of service provision. Keywords Urology Subspecialty On-call activity European working time directive EWTD
Introduction The trend towards subspecialisation has led to the development of urology on-call services in most tertiary hospitals. However, due to budget constraints, many institutions are being forced to consider removing middle grade cover from subspecialty ‘‘out of hours’’ services. Although eliminating the cost of maintaining a call rota, this solution does not take into account the potential expenditure saved by providing an on-call service. Furthermore, the decision to remove subspecialty cover is often made without taking into account the volume and type of workload undertaken by Non-Consultant Hospital Doctors (NCHDs) out-ofhours and the effect that removing middle grade cover has on both patient care pathways and the training opportunities of junior staff. The introduction of the New Surgical Training Pathway in Ireland [1] and Modernising Medical Careers (MMC) in the UK [2] has created a challenge for teaching hospitals to ensure that trainees continue to achieve the same competencies in a shorter time period. The enforced implementation of the European Working Time Directive (EWTD) [3] has complicated this issue further resulting in decreased
123
Ir J Med Sci
clinical exposure and operative training time [4–7]. Furthermore, the requirement for earlier subspecialisation means that in time, general surgical trainees may not undergo formal training in urology and may lack sufficient experience to safely manage urological emergencies on call. A survey of general surgical trainees in the UK revealed that the majority of trainees had never undertaken rotations in urology and less than one-third felt they should be providing urology on-call cover [8]. The management of urological emergencies by doctors who have had no defined urological training or competency assessment has potential implications in relation to clinical governance. The purpose of this study was to audit the emergency urology activity in our institution over a 12-month period with the aim of informing future policy changes in this area.
Service description The mid-western region is comprised of counties Limerick, Clare and North Tipperary and serves an estimated population of 380,000 [9]. Our urology service operates on four sites—University Hospital Limerick, Ennis General Hospital, Nenagh General Hospital and St. John’s Hospital, Limerick. Although outpatient services, investigative work and day case procedures are carried out on each of the four sites, emergency and inpatient urology is centralised to the University Hospital Limerick. Out-of-hours cover is provided by three consultant urologists who carry out a 1:3 weekly call rota. The middle grade rota is shared by six NCHDs including one specialist registrar, three basic speciality trainee registrars and two research registrars. Round the clock access is available to one emergency theatre, which is shared between all specialities.
Methods A prospective logbook was kept of all urology referrals from the emergency department (ED) over a 12-month period between August 2012 and July 2013. The time and date of each referral was recorded in addition to the diagnosis and outcome. The emergency theatre logbook was retrospectively evaluated for emergency urological procedures carried out over the same period. The results were collated on a secure protected database (Microsoft Excel, WA, USA) and analysed using SPSS (IBM, NY, USA). For the purpose of analysis, the term ‘‘out of hours’’ was taken to mean any time outside of the approved normal working hours of our service i.e. any time outside of Monday–Friday, 7 am–7 pm. The term ‘‘overnight’’ was taken to mean any referrals seen between 7 pm and 7 am the following morning.
123
Results Overall, 752 referrals were seen in the ED over a 12-month period. This resulted in 444 admissions and 308 discharges. An average of 63 referrals was received per month (Fig. 1). The most common reasons for referral were suspected renal colic or scrotal problems (Fig. 2). A total of 60.5 % of those referred with renal colic were admitted (167/276), and the majority of these patients required either ureteric stent placement or definitive management of the stone. Most of the patients referred with scrotal problems complained of acute scrotal pain (79 %, 130/165). The majority of ED referrals (55.9 %) were seen outside of normal working hours (Fig. 3). This included 59.2 % of those presenting with acute scrotal pain (77/130) and 86.8 % of trauma presentations (33/38). The overall discharge rate was 41 % (308/752). Approximately 45.7 % of referrals seen during the day were discharged (199/435). In contrast, only 35.5 % of referrals seen overnight were discharged (106/299). This difference was statistically significant (p = \0.005, missing data = 18). A total of 167 emergency procedures were performed over the same 12-month period. The majority of these procedures were endourological (Fig. 4). As there is no emergency interventional radiology service in our institution, all obstructing stones requiring intervention are managed endoscopically. Over half of all emergency operations were carried out outside of normal working hours (53.9 %, 90/167) (Fig. 5). This included 54.1 % of scrotal explorations (13/24) and 30 % of renal stone procedures (31/104). Of the 24 scrotal explorations performed, there were nine cases of testicular torsion (seven salvageable, two unsalvageable) and nine torted cysts of morgagni. The outcome of the remaining six explorations was not recorded in the prospective logbook. A basic cost analysis was performed on the recorded data. The total cost of providing middle grade out-of-hours cover was estimated at €117,877 per annum. This was calculated using the first point of the specialist registrar salary scale (€29.785/h) [10], as this was the average salary increment of the registrars responsible for covering the middle grade rota (Fig. 6). The amount of hours spent on site was not recorded prospectively and was calculated based on an average estimate of 2 h spent seeing each referral and 2 h per day spent on the ward round each weekend. The time spent performing emergency operations or seeing inpatient consults was not analysed. The annual cost saved by discharging 157 of the 420 patients seen outside of normal service hours was estimated at €175,997. This figure was calculated using an average daily bed rate of €1,121 [11]. Therefore, the provision of urology cover out-of-hours resulted in an estimated cost saving of €58,120 [€175,997–€117,877].
Ir J Med Sci Fig. 1 Number of patients referred from the emergency department per month
Fig. 2 Diagnosis of patients referred from the emergency department
Fig. 3 Time of day when ED referrals were received
Discussion The introduction of the European Working Time Directive (EWTD) has resulted in a shift towards new on-call working arrangements. This study highlights the large volume of emergency urology activity carried out at our institution; a significant amount of which occurs outside of normal working hours. The majority of emergency operations (53.9 %) and referrals from the emergency department (55.9 %) took place ‘‘on-call’’, however this is only a
proportion of the entire workload and does not address the time spent seeing consults from other specialities, receiving phone calls from colleagues or reviewing urology inpatients on the ward. Care must be taken to ensure that the transfer of this workload is taken into account when alternative work schedules are being considered. Adapting to the EWTD has been particularly difficult for smaller subspecialties such as urology, where the number of middle grade staff contributing to the call rota is often limited. The pressure to achieve EWTD compliance combined with economical demands to reduce hospital expenditure has forced several institutions to limit emergency urology cover to normal working hours, leaving the general surgical team on call to take responsibility for any urological emergencies arising outside of this period [8]. Removing out-of-hours cover at our institution would eliminate a urology trainee’s exposure to 59.2 % of acute scrotal pain presentations and 54.1 % of emergency scrotal explorations. Furthermore, only 13 % of all trauma presentations were seen during normal working hours. The reconfiguration of surgical training pathways has created the challenge of ensuring that the required training
123
Ir J Med Sci Fig. 4 Types of emergency procedures performed
Fig. 5 Time of day when emergency surgery was performed
Fig. 6 Basic cost analysis of the out-of-hours service
opportunities are provided in a shorter time period. Many opponents of the EWTD criticise the effect that the compensatory rest periods have on a trainee’s operative exposure. In fact, several studies have cited a [20 % reduction in the number of procedures performed by trainees since implementation of the directive [4–7]. However, emergency and elective patient care are held to the same standards of clinical governance [12, 13]. Therefore, it is equally important that urology trainees are competent in
123
managing common urological emergencies by the end of their specialist training. All trainees, irrespective of their core speciality, who are responsible for managing urological emergencies should undergo competency assessment and training to ensure quality of care standards are being maintained. Our study found that the percentage of patients discharged overnight was significantly lower than the discharge rate during the day (35.5 vs. 45.7 %). There are a number of explanations for this observation. Patients with minor illnesses are more likely to present during normal working hours, which means that the cohort of patients presenting by night is different from those who present during the day [14]. Secondly, it is often necessary to admit patients overnight if the investigation of choice is not available outside of normal working hours. Finally, patients may occasionally require admission for a period of observation if the diagnosis is unclear or to allow them to be reviewed by the consultant the following morning. Basic cost calculations show that providing out-ofhours urology cover is an efficient method of service provision, resulting in an approximate cost saving of €58,120 per annum. These calculations were based on the presumption that the removal of the on-call service would not alter the number of referrals received. It was also assumed that all referred patients would otherwise be admitted by the general surgical team on call, for urology review the following morning. Finally, the financial benefit that an out-of-hours referral might have on reducing a patient’s morbidity or overall length of stay was not captured by our study. One previous study examined the impact that removing emergency urology cover had on the management of obstructing ureteric
Ir J Med Sci
calculi. This study found that restricting out-of-hours urology cover increased patient morbidity and was associated with an estimated financial burden of £33,000/annum (€40,130) [15]. Additional research will be necessary to calculate an accurate cost analysis, which encompasses all aspects of maintaining an on-call service. Nevertheless, our study demonstrates a significant cost benefit to providing urology cover out-ofhours.
Conclusion In conclusion, emergency urology activity contributes to a significant workload at our institution. Restricting emergency urology cover limits essential training opportunities for urology trainees and can compromise patient care pathways. ‘‘Out of hours’’ urology cover represents a costeffective method of service provision, however an in-depth cost analysis would be useful to further evaluate the actual cost savings. Conflict of interest
Ms. Redmond has nothing to disclose.
References 1. The Royal College of Surgeons of Ireland. New Surgical Training Pathway. 2012. Available online: http://www.rcsi.ie/aboutsurgi caltrainingpathway. Accessed on: 22/11/13 2. The Royal College of Surgeons of England. Developing a Modern Surgical Workforce. 2005. Available online: www. rcseng.ac.uk/services/publications/publications/index_html?pub_ id=177. Accessed on: 22/11/13 3. (1993) European Council Directive 93/104/EC. Official J Eur Commun. L307: 18–24
4. Benes V (2006) The European working time directive and the effects on training of surgical specialists (doctors in training). Acta Neurochir (Wien) 148(9):1020–1026 5. Breen KJ, Hogan AM, Mealy K (2013) The detrimental impact of the implementation of the European working time directive (EWTD) on surgical senior house officer (SHO) operative experience. Ir J Med Sci 182(3):383–387 6. Bates T, Slade D (2007) The impact of the European working time directive on operative exposure. Ann R Coll Surg Engl 89(4):452 7. Stephens MR, Pellard S, Boyce J et al (2004) Influence of EWTD-compliant rotas on SHO operative experience. Ann R Coll Surg Engl 86:120–121 8. Thiruchelvam N, Adamson A (2006) Competency and training of general surgery specialist registrars in emergency urology. BJU Int 98(1):6–7 9. Central Statistics Office, Cork, Ireland. CD102: Actual and percentage change in population by Province or County, CensusYear and Statistic. Available online at: [http://www.cso.ie] Accessed: 20/11/2013 10. Health Service Executive. Contract of employment for Nonconsultant hospital doctors. Available online at: [www.medicine. tcd.ie/assets/doc/NCHD-Contract.doc]. Accessed: 20/11/13 11. Health Service Executive. Hospital charges. Available online: [http://www.hse.ie/eng/services/list/3/hospitals/Hospitalcharges. html]. Accessed: 20/11/13 12. Health Services Executive. Admissions and discharges guidelines. Available online at: http://www.dohc.ie/issues/health_strat egy/action84.pdf?direct=1. Accessed on: 20/11/13 13. NHS England. High quality care for all, now and for future generations: Transforming urgent and emergency care services in England. The Evidence Base from the Urgent and Emergency Care Review. Available online at: [http://www.england.nhs.uk/ wp-content/uploads/2013/06/urg-emerg-care-ev-bse.pdf]. Accessed on: 20/11/13 14. Nagree Y et al (2013) Quantifying the proportion of general practice and low-acuity patients in the emergency department. Med J Aust 198(11):612–615 15. Hellawell GO, Kahn L, Mumtaz F (2005) The European working time directive: implications for subspecialty acute care. Int J Clin Pract 59(5):508–510
123
ORIGINAL ARTICLE
A prospective audit of emergency urology activity in a university teaching hospital E. J. Redmond • J. C. Forde • M. A. Abdelrahman N. P. Kelly • C. Akram • S. K. Giri • H. D. Flood
•
Received: 31 January 2014 / Accepted: 26 May 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Introduction Urology cover is commonly available outof-hours in most teaching hospitals. However, increased pressure to reduce hospital expenditure has forced many institutions to consider removing middle grade cover outside of normal working hours. The aim of this study was to audit the emergency urology activity in our institution over a 12-month period. Methods A prospective logbook was maintained for all urology referrals from the emergency department between August 2012 and March 2013. The diagnosis and patient outcome was recorded for each referral. The emergency theatre logbook was retrospectively evaluated for all emergency urology procedures carried out over the same time period. A basic cost analysis was performed to calculate the cost of providing the on-call service. Results A total of 752 patients were referred to the urology service over a 12-month period. The most common reasons for referral were renal colic and scrotal pain. Approximately 41 % of referrals were discharged directly from the emergency department. There were 167 emergency operations performed in total. The majority of emergency operations and referrals from the emergency department took place outside of normal working hours. A basic cost analysis revealed an associated cost saving of €58,120.
This work received the ISU Registrar’s Prize when presented at the Irish Society of Urology annual meeting in September 2013. E. J. Redmond (&) J. C. Forde M. A. Abdelrahman N. P. Kelly C. Akram S. K. Giri H. D. Flood Department of Urology, University Hospital Limerick, Dooradoyle, Limerick, Ireland e-mail: [email protected]
Conclusion Emergency urology activity constitutes a large proportion of the workload at our institution. Restricting emergency urology cover would limit essential training opportunities for urology trainees, increases length of stay and delay treatment of urological emergencies. Urology ‘‘out of hours’’ cover is a cost-efficient method of service provision. Keywords Urology Subspecialty On-call activity European working time directive EWTD
Introduction The trend towards subspecialisation has led to the development of urology on-call services in most tertiary hospitals. However, due to budget constraints, many institutions are being forced to consider removing middle grade cover from subspecialty ‘‘out of hours’’ services. Although eliminating the cost of maintaining a call rota, this solution does not take into account the potential expenditure saved by providing an on-call service. Furthermore, the decision to remove subspecialty cover is often made without taking into account the volume and type of workload undertaken by Non-Consultant Hospital Doctors (NCHDs) out-ofhours and the effect that removing middle grade cover has on both patient care pathways and the training opportunities of junior staff. The introduction of the New Surgical Training Pathway in Ireland [1] and Modernising Medical Careers (MMC) in the UK [2] has created a challenge for teaching hospitals to ensure that trainees continue to achieve the same competencies in a shorter time period. The enforced implementation of the European Working Time Directive (EWTD) [3] has complicated this issue further resulting in decreased
123
Ir J Med Sci
clinical exposure and operative training time [4–7]. Furthermore, the requirement for earlier subspecialisation means that in time, general surgical trainees may not undergo formal training in urology and may lack sufficient experience to safely manage urological emergencies on call. A survey of general surgical trainees in the UK revealed that the majority of trainees had never undertaken rotations in urology and less than one-third felt they should be providing urology on-call cover [8]. The management of urological emergencies by doctors who have had no defined urological training or competency assessment has potential implications in relation to clinical governance. The purpose of this study was to audit the emergency urology activity in our institution over a 12-month period with the aim of informing future policy changes in this area.
Service description The mid-western region is comprised of counties Limerick, Clare and North Tipperary and serves an estimated population of 380,000 [9]. Our urology service operates on four sites—University Hospital Limerick, Ennis General Hospital, Nenagh General Hospital and St. John’s Hospital, Limerick. Although outpatient services, investigative work and day case procedures are carried out on each of the four sites, emergency and inpatient urology is centralised to the University Hospital Limerick. Out-of-hours cover is provided by three consultant urologists who carry out a 1:3 weekly call rota. The middle grade rota is shared by six NCHDs including one specialist registrar, three basic speciality trainee registrars and two research registrars. Round the clock access is available to one emergency theatre, which is shared between all specialities.
Methods A prospective logbook was kept of all urology referrals from the emergency department (ED) over a 12-month period between August 2012 and July 2013. The time and date of each referral was recorded in addition to the diagnosis and outcome. The emergency theatre logbook was retrospectively evaluated for emergency urological procedures carried out over the same period. The results were collated on a secure protected database (Microsoft Excel, WA, USA) and analysed using SPSS (IBM, NY, USA). For the purpose of analysis, the term ‘‘out of hours’’ was taken to mean any time outside of the approved normal working hours of our service i.e. any time outside of Monday–Friday, 7 am–7 pm. The term ‘‘overnight’’ was taken to mean any referrals seen between 7 pm and 7 am the following morning.
123
Results Overall, 752 referrals were seen in the ED over a 12-month period. This resulted in 444 admissions and 308 discharges. An average of 63 referrals was received per month (Fig. 1). The most common reasons for referral were suspected renal colic or scrotal problems (Fig. 2). A total of 60.5 % of those referred with renal colic were admitted (167/276), and the majority of these patients required either ureteric stent placement or definitive management of the stone. Most of the patients referred with scrotal problems complained of acute scrotal pain (79 %, 130/165). The majority of ED referrals (55.9 %) were seen outside of normal working hours (Fig. 3). This included 59.2 % of those presenting with acute scrotal pain (77/130) and 86.8 % of trauma presentations (33/38). The overall discharge rate was 41 % (308/752). Approximately 45.7 % of referrals seen during the day were discharged (199/435). In contrast, only 35.5 % of referrals seen overnight were discharged (106/299). This difference was statistically significant (p = \0.005, missing data = 18). A total of 167 emergency procedures were performed over the same 12-month period. The majority of these procedures were endourological (Fig. 4). As there is no emergency interventional radiology service in our institution, all obstructing stones requiring intervention are managed endoscopically. Over half of all emergency operations were carried out outside of normal working hours (53.9 %, 90/167) (Fig. 5). This included 54.1 % of scrotal explorations (13/24) and 30 % of renal stone procedures (31/104). Of the 24 scrotal explorations performed, there were nine cases of testicular torsion (seven salvageable, two unsalvageable) and nine torted cysts of morgagni. The outcome of the remaining six explorations was not recorded in the prospective logbook. A basic cost analysis was performed on the recorded data. The total cost of providing middle grade out-of-hours cover was estimated at €117,877 per annum. This was calculated using the first point of the specialist registrar salary scale (€29.785/h) [10], as this was the average salary increment of the registrars responsible for covering the middle grade rota (Fig. 6). The amount of hours spent on site was not recorded prospectively and was calculated based on an average estimate of 2 h spent seeing each referral and 2 h per day spent on the ward round each weekend. The time spent performing emergency operations or seeing inpatient consults was not analysed. The annual cost saved by discharging 157 of the 420 patients seen outside of normal service hours was estimated at €175,997. This figure was calculated using an average daily bed rate of €1,121 [11]. Therefore, the provision of urology cover out-of-hours resulted in an estimated cost saving of €58,120 [€175,997–€117,877].
Ir J Med Sci Fig. 1 Number of patients referred from the emergency department per month
Fig. 2 Diagnosis of patients referred from the emergency department
Fig. 3 Time of day when ED referrals were received
Discussion The introduction of the European Working Time Directive (EWTD) has resulted in a shift towards new on-call working arrangements. This study highlights the large volume of emergency urology activity carried out at our institution; a significant amount of which occurs outside of normal working hours. The majority of emergency operations (53.9 %) and referrals from the emergency department (55.9 %) took place ‘‘on-call’’, however this is only a
proportion of the entire workload and does not address the time spent seeing consults from other specialities, receiving phone calls from colleagues or reviewing urology inpatients on the ward. Care must be taken to ensure that the transfer of this workload is taken into account when alternative work schedules are being considered. Adapting to the EWTD has been particularly difficult for smaller subspecialties such as urology, where the number of middle grade staff contributing to the call rota is often limited. The pressure to achieve EWTD compliance combined with economical demands to reduce hospital expenditure has forced several institutions to limit emergency urology cover to normal working hours, leaving the general surgical team on call to take responsibility for any urological emergencies arising outside of this period [8]. Removing out-of-hours cover at our institution would eliminate a urology trainee’s exposure to 59.2 % of acute scrotal pain presentations and 54.1 % of emergency scrotal explorations. Furthermore, only 13 % of all trauma presentations were seen during normal working hours. The reconfiguration of surgical training pathways has created the challenge of ensuring that the required training
123
Ir J Med Sci Fig. 4 Types of emergency procedures performed
Fig. 5 Time of day when emergency surgery was performed
Fig. 6 Basic cost analysis of the out-of-hours service
opportunities are provided in a shorter time period. Many opponents of the EWTD criticise the effect that the compensatory rest periods have on a trainee’s operative exposure. In fact, several studies have cited a [20 % reduction in the number of procedures performed by trainees since implementation of the directive [4–7]. However, emergency and elective patient care are held to the same standards of clinical governance [12, 13]. Therefore, it is equally important that urology trainees are competent in
123
managing common urological emergencies by the end of their specialist training. All trainees, irrespective of their core speciality, who are responsible for managing urological emergencies should undergo competency assessment and training to ensure quality of care standards are being maintained. Our study found that the percentage of patients discharged overnight was significantly lower than the discharge rate during the day (35.5 vs. 45.7 %). There are a number of explanations for this observation. Patients with minor illnesses are more likely to present during normal working hours, which means that the cohort of patients presenting by night is different from those who present during the day [14]. Secondly, it is often necessary to admit patients overnight if the investigation of choice is not available outside of normal working hours. Finally, patients may occasionally require admission for a period of observation if the diagnosis is unclear or to allow them to be reviewed by the consultant the following morning. Basic cost calculations show that providing out-ofhours urology cover is an efficient method of service provision, resulting in an approximate cost saving of €58,120 per annum. These calculations were based on the presumption that the removal of the on-call service would not alter the number of referrals received. It was also assumed that all referred patients would otherwise be admitted by the general surgical team on call, for urology review the following morning. Finally, the financial benefit that an out-of-hours referral might have on reducing a patient’s morbidity or overall length of stay was not captured by our study. One previous study examined the impact that removing emergency urology cover had on the management of obstructing ureteric
Ir J Med Sci
calculi. This study found that restricting out-of-hours urology cover increased patient morbidity and was associated with an estimated financial burden of £33,000/annum (€40,130) [15]. Additional research will be necessary to calculate an accurate cost analysis, which encompasses all aspects of maintaining an on-call service. Nevertheless, our study demonstrates a significant cost benefit to providing urology cover out-ofhours.
Conclusion In conclusion, emergency urology activity contributes to a significant workload at our institution. Restricting emergency urology cover limits essential training opportunities for urology trainees and can compromise patient care pathways. ‘‘Out of hours’’ urology cover represents a costeffective method of service provision, however an in-depth cost analysis would be useful to further evaluate the actual cost savings. Conflict of interest
Ms. Redmond has nothing to disclose.
References 1. The Royal College of Surgeons of Ireland. New Surgical Training Pathway. 2012. Available online: http://www.rcsi.ie/aboutsurgi caltrainingpathway. Accessed on: 22/11/13 2. The Royal College of Surgeons of England. Developing a Modern Surgical Workforce. 2005. Available online: www. rcseng.ac.uk/services/publications/publications/index_html?pub_ id=177. Accessed on: 22/11/13 3. (1993) European Council Directive 93/104/EC. Official J Eur Commun. L307: 18–24
4. Benes V (2006) The European working time directive and the effects on training of surgical specialists (doctors in training). Acta Neurochir (Wien) 148(9):1020–1026 5. Breen KJ, Hogan AM, Mealy K (2013) The detrimental impact of the implementation of the European working time directive (EWTD) on surgical senior house officer (SHO) operative experience. Ir J Med Sci 182(3):383–387 6. Bates T, Slade D (2007) The impact of the European working time directive on operative exposure. Ann R Coll Surg Engl 89(4):452 7. Stephens MR, Pellard S, Boyce J et al (2004) Influence of EWTD-compliant rotas on SHO operative experience. Ann R Coll Surg Engl 86:120–121 8. Thiruchelvam N, Adamson A (2006) Competency and training of general surgery specialist registrars in emergency urology. BJU Int 98(1):6–7 9. Central Statistics Office, Cork, Ireland. CD102: Actual and percentage change in population by Province or County, CensusYear and Statistic. Available online at: [http://www.cso.ie] Accessed: 20/11/2013 10. Health Service Executive. Contract of employment for Nonconsultant hospital doctors. Available online at: [www.medicine. tcd.ie/assets/doc/NCHD-Contract.doc]. Accessed: 20/11/13 11. Health Service Executive. Hospital charges. Available online: [http://www.hse.ie/eng/services/list/3/hospitals/Hospitalcharges. html]. Accessed: 20/11/13 12. Health Services Executive. Admissions and discharges guidelines. Available online at: http://www.dohc.ie/issues/health_strat egy/action84.pdf?direct=1. Accessed on: 20/11/13 13. NHS England. High quality care for all, now and for future generations: Transforming urgent and emergency care services in England. The Evidence Base from the Urgent and Emergency Care Review. Available online at: [http://www.england.nhs.uk/ wp-content/uploads/2013/06/urg-emerg-care-ev-bse.pdf]. Accessed on: 20/11/13 14. Nagree Y et al (2013) Quantifying the proportion of general practice and low-acuity patients in the emergency department. Med J Aust 198(11):612–615 15. Hellawell GO, Kahn L, Mumtaz F (2005) The European working time directive: implications for subspecialty acute care. Int J Clin Pract 59(5):508–510
123
