European Working Time Directive in a stroke unit: hidden deficits.

Sir, The study by Cappucio et al. 1 argues that the 48-h working limit per week can improve patient safety when the range of the working week period is reduced. Their data have been criticized, in part because of the casemix variation between the traditional and intervention arms of the study and unblinding of the initial nurse assessors of medical errors. 2,3 As the authors explain, retrospective case note review relies heavily on 'accuracy, completeness and legibility' of the medical records. 4 Lack of documentation may hide a medical error. We became aware of this possibility in 2005 when we audited junior doctor attendance on our acute stroke unit (ASU). 5 We prospectively identified over a 3-month period that junior doctors were not present on the ASU for 28% of working weekdays with the 56-h limit European Working Time Directive (EWTD). We alerted our local risk management , presented our findings at a Trust Audit symposium and published our findings so that we might improve on this process measure of quality as there is emerging evidence that measures of process may be useful audit instruments to improve patient care. 6 In 2009, we prospectively re-audited this measure of process primarily because of mounting concerns from the nursing and consultant staff that daily clinical care remained a problem. We prospectively recorded junior doctor attendance on our ASU We also analysed whether junior doctors contributed to the stroke unit by performing a task list and/or clinical review of patients. Junior doctors were blind to the audit. Fifty-two patients were admitted to the ASU over the 3-month period, 31 men and 21 women, mean age 68 (12.2 SD) years. Of 62 available working weekdays, a Specialist Training (ST) doctor or Specialist Registrar (SpR) assessed patients on 7 days (11%). Patients were clinically reviewed by any junior doctor on 26 days (42%). Programme Foundation (PF) 1 or 2 doctors completed a task list on 44 days (71%). On 7 working weekdays (11%) no junior doctor attended the ASU, an improvement from 2005. Other comparisons with the 2005 audit are shown in the Table 1. Our study recorded improvement in two of three parameters between the two audits. However, this may not be clinically important, particularly as ST/SpR attendances have severely decreased to just 11% of working weekdays. Task list activity contributed to the apparent improvement, but we suspect that this type of patient care …