The problems faced by an OOH vet - you can help

Re: The problems faced by an OOH vet - you can help

Wren — Fri, 20 Dec 2013 10:42:08 GMT

[quote user="robloxley"]

[quote user="Wren"]cue phones ringing off the hook as owners look at their histories and ring to complain[/quote]

[quote user="Wren"]a read through the notes was worth 10 ECGs to me in that situation[/quote]

So you either don't have access to the notes, navigate the minefield of the DPA to allow the OOH vet direct access to the notes, or allow the client access to the notes (which they can request to see anyway, so shouldn't be hiding any nasty surprises...)?
For ops, especially anything major or that might have potential complications, a good set of discharge instructions and an well-itemised bill go a long way. Doesn't help with the CHF dog that de-compensates into an acute crisis out of the blue though.

[/quote]

I think there's a line between providing histories on request (and I'm pretty careful never to write anything that I wouldn't want the client to see) and allowing every client to be able to log in to their record at will, possibly late at night with a drink in one hand and with only the expertise of internet forums (yes, I get the irony) available to interpret the medical terminology for them.

Re: The problems faced by an OOH vet - you can help

Jenny Smith — Fri, 20 Dec 2013 02:25:38 GMT

This is a brilliant thread! As an out of hours (Vets Now) vet, I do often get the out of the blue phone calls about the case which has been in and out of the vets all week 'cause his breathin ain't good luv'. All it would take is a 'just in case' history fax from the day time practice.

I know when I worked in a larger practice as part of an on call rota, we would try and let the other vets know if we had seen something during the day that might end up coming back in. Why not extend that to the off site OOH provider?

Some of our member practices do send us these just in case faxes/emails, and we had a lovely phone call a few months back from a locum who had done a hind limb amputation that day. He went through exactly which meds the dog was on, timings and what it had been sent home with. The clients were financially limited, so really appreciated us being able to say 'give him the tramadol tablet your vet sent you home with, he can have that now as his last dose of opiods were at whatever time'.

Simple things....

Re: The problems faced by an OOH vet - you can help

Rob Loxley — Thu, 19 Dec 2013 22:56:43 GMT

[quote user="Wren"]cue phones ringing off the hook as owners look at their histories and ring to complain[/quote]

[quote user="Wren"]a read through the notes was worth 10 ECGs to me in that situation[/quote]

Re: The problems faced by an OOH vet - you can help

Virginia Campbell — Thu, 19 Dec 2013 18:15:41 GMT

[quote user="Wren"] notes were invaluable for these so that you knew which were likely to be OK with some medicine tweaking and which had had every drug under the sun and were at the end of the road[/quote]

yep, I guess the human paramedics and A+E doctors have to just go full blast trying to save everyone regardless of pain and distress being experienced by the patient/distress to family/cost whereas we don't and if the GP notes say "coming to the end, will need euth if any further episodes" then that would help an OOH vet trying to talk a can't-let-go owner into euth.

Re: The problems faced by an OOH vet - you can help

Neil Wheadon — Thu, 19 Dec 2013 12:47:11 GMT

[quote user="Michael Woodhouse"]Neil, I appreciate that, yet the ambulance service and A&E seem to manage with people. I suppose that was the point I was making[/quote]

Ah yes, but is it ideal?

We could be better than that couldn't we?

Neil

Re: The problems faced by an OOH vet - you can help

Hannah Wynne Richards — Thu, 19 Dec 2013 12:21:38 GMT

Holidaymakers who forget to pack the dog's medication and com in for "arthritis tablets"

Wynne

Re: The problems faced by an OOH vet - you can help

Wren — Thu, 19 Dec 2013 12:04:26 GMT

[quote user="robloxley"]

Maybe the answer is to allow access for the client to their own records, rather than giving the OOH provider blanket access, like som PMS do for online booking of appointments and repeats ordering?

[/quote]

Apparently this is happening already in The States - cue phones ringing off the hook as owners look at their histories and ring to complain about the bloods that they were told were normal when actually ALT was one unit outside the upper range. Sounds like my idea of hell!

In the old days when I did SA OOH a lot of cases were holiday makers, GI upsets, RTAs, stitch-ups etc. ie. new conditions so a history was largely irrelevant. However I did seem to get quite a lot of cardiac cases and similar which had destabilised in the middle of the night (or just been noticed in the middle of the night...) and notes were invaluable for these so that you knew which were likely to be OK with some medicine tweaking and which had had every drug under the sun and were at the end of the road. Sure, you can do tests, but a read through the notes was worth 10 ECGs to me in that situation.

ETA - apologies, I see Neil has already made that point!

Re: The problems faced by an OOH vet - you can help

Michael Woodhouse — Wed, 18 Dec 2013 18:39:41 GMT

[quote user="Neil Wheadon"]OOH is more than emergencies, I often see continuations on heart medication or other therapies and it's tough figuring the doses involved. Dogs have fitted during the day and bitches have been given oxytocin then sent home.[/quote]

Neil, I appreciate that, yet the ambulance service and A&E seem to manage with people. I suppose that was the point I was making.

Re: The problems faced by an OOH vet - you can help

Bob Russell — Wed, 18 Dec 2013 14:46:07 GMT

I am surprised that there is much competition for OOH's work. The problems operating the business and slim margins make it hard going. If someone opens up with a team of out of hours 'meat inspectors' I am sure they would make a lot more money per client for the business owners!

Feeling a little raw because came in to a collapsed and dying kitten that had just had its second pet shop back room vaccination and it seems to have missed the vets attention that the kitten was a walking hatrack and tiny for its age. Any quarter decent clinician would have known this is a pet with problems. Still stack 'em high and sell 'em cheap as they say. At least it died with a 99p chip in its neck!

There are far bigger problems in this profession than the latest DC case.

Re: The problems faced by an OOH vet - you can help

Francisco Gomez — Wed, 18 Dec 2013 14:09:25 GMT

[quote user="Neil Wheadon"]

What we need is single centres with several vets, not individual clinics with isolated individuals. (Solo working is another downer to OOH work)

[/quote]

This is very true. I had done shifts on my own and with other vet at OOH clinics.

When you have two vets in one clinic, you manage cases and waiting times much better. It's not only +1 vet, it is much more than that. Sometimes you have a little stitch up that would take 10 minutes, but you simply can't do it (the dog may have to sit in the kennel for hours), because there is a fitting dog in the way and two people sitting in the waiting room!

Re: The problems faced by an OOH vet - you can help

Neil Wheadon — Wed, 18 Dec 2013 13:53:35 GMT

[quote user="Michael Woodhouse"]Even the NHS can't manage to integrate the GP and hospital notes[/quote]

True, our daughter had an MRI done at Bath RUH and Frenchay hospital in Bristol can't read the file

[quote user="Michael Woodhouse"]I do think that people do seem to attach almost too much significance to a history[/quote]

In most cases maybe. In others no. I'm at an advantage as locum so know nearly all the drugs out there so can link it. A client recently had a dog on pain relief, ' It's Gab...something' they say, if I said Gabapentin then I've cracked it, but it's tough to make that link when vets go off licence. OOH is more than emergencies, I often see continuations on heart medication or other therapies and it's tough figuring the doses involved. Dogs have fitted during the day and bitches have been given oxytocin then sent home.

It is a partnership and as the relationship matures it needs to be seen this way.

Neil

Re: The problems faced by an OOH vet - you can help

Rob Loxley — Wed, 18 Dec 2013 13:46:07 GMT

[quote user="Bob Russell"]The PMS providers should really start preparing a secure way of allowing access to histories but clearly this is fraught with issues over security and client confidentiality as well as the massive technical issues[/quote]

Maybe the answer is to allow access for the client to their own records, rather than giving the OOH provider blanket access, like som PMS do for online booking of appointments and repeats ordering?

Re: The problems faced by an OOH vet - you can help

Neil Wheadon — Wed, 18 Dec 2013 13:39:41 GMT

[quote user="Bob Russell"]Long term I would expect a core of experienced vets used to dealing with the OOH type jobs. Hopefully students and newer graduates will use it to get experience at the sharp end (under adequate supervision).[/quote]

I can't do the multiple quote thing so I'll answer these individually

The above is the Vets Now model at present. 8 districts and 8 very experienced vets that have been with the company for many year. Their remit is to oversee their clinics and do shifts in each. They look at clinical histories and offer advise to other vets within the company. A lot have extra training which I'm part of, looking at advanced emergency medicine and all attend conferences both here and abroad.

There are 2 problems with OOH vets

1) There is a life span to this and in my opinion it is 10 years Doing 6 nights every 14 days is draining. I have worked with Vets Now for 8 years and do about 40-50 nights a year which for me is enough. Therefore there will be a turnover it's inevitable.

2) I have had 2 E Mails offering OOH jobs as start ups. Other companies are looking at the Vets Now model with envious eyes and are trying to open up clinics in competition. Vets Now cannot staff the vast majority of clinics with more than one vet at the moment and this is cost driven (We did have 2 staff on Sunday but with day practices now opening Sundays this has gone now). If client throughput decreases due to competition, wages will inevitably be depressed and quality staff won't do it. What we need is single centres with several vets, not individual clinics with isolated individuals. (Solo working is another downer to OOH work)

The idea of feedback@vetsnow is a good one, I'll pass this up the foodchain!!

Neil

Re: The problems faced by an OOH vet - you can help

Tim Browning — Wed, 18 Dec 2013 13:05:23 GMT

That's why I have my medical history tattooed on my chest, with a lovely ornate font...be on my back too soon

Re: The problems faced by an OOH vet - you can help

Michael Woodhouse — Wed, 18 Dec 2013 11:52:51 GMT

Even the NHS can't manage to integrate the GP and hospital notes. With the ever growing numbers of practice management systems I can't see this ever happening. There could be a OOH provider read only log on to the cloud based systems I suppose, but being familiar with all the systems would be nearly impossible.

I do think that people do seem to attach almost too much significance to a history, particularly in the case of an emergency. We see quite a few holidaymakers in the summer (particularly) and ask that they bring any medication with them. I'd say it was actually rare that the clinical history (when available) makes very much difference.

The situation is very different to a client moving to the area with an ongoing chronic condition, where without a history it is very easy to repeat what has already being done, or try an already tried intervention that was not effective.

Re: The problems faced by an OOH vet - you can help

Bob Russell — Wed, 18 Dec 2013 11:35:04 GMT

I am a great supporter of quality dedicated OOH care. VetsNow is a recent business model that is very much a work in progress and probably will be for many years to come.

Long term I would expect a core of experienced vets used to dealing with the OOH type jobs. Hopefully students and newer graduates will use it to get experience at the sharp end (under adequate supervision).

Clients will in time figure out that OOH's care done properly is expensive and need to prepare for the occasional emergency. This is all pretty much in line with human A+E (without the big budget of course).

We try to manage client expectation by explaining OOH arrangements from their first visit. Most accept it but many are registered at more than one practice so do tend to go for convenience!

The PMS providers should really start preparing a secure way of allowing access to histories but clearly this is fraught with issues over security and client confidentiality as well as the massive technical issues. I doubt this option will ever happen

Perhaps VetsNow should offer a feedback@VetsNowSouthampton email address. I am perfectly happy to provide feedback!

Our experiences with VetsNow are generally very positive

Re: The problems faced by an OOH vet - you can help

David Mills — Wed, 18 Dec 2013 11:34:47 GMT

I agree with what Mr Wheadon has said wholeheartedly, as someone who has done several Vets Now shifts and extensive on call in other jobs.

I would only add:

1) Vets do things differently and achieve the same outcome. If you're wondering about why something was or was not done, then ask us. Don't accuse or long diatribes criticising aspects of the case without asking. There are usually very good reasons why or why not something was done. Many vets working in OOH have an interest in the area and its an emerging field in terms of knowledge. We cannot write all our reasoning in the clinical notes or we'd be continually writing notes.

2) Everything looks different in retrospect and when the owner is spinning you their version of events, normally informed by being pissed off about prices or not getting off their arse earlier to get the animal seen.