Under current arrangements some doctors have opted not to perform Out of Hours (OOH) duties at all, and some perform a mixture of in-hours duties and OOH sessions. There are a small number of Doctors who either exclusively or mainly perform OOH duties. If you are performing OOH work this will need to be discussed with your appraiser and should be listed under “my activities” on the MARS site.

This section of the resource contains support material in the following areas of practice.

Domain 1 - Knowledge skills and performance
Prescribing habits, Emergency admissions, Medical Records, Reflecting on your learning in OOH care, Reflecting on your learning – Puns and Dens

Domain 2 - Safety and Quality
Significant event analysis, Emergency care

Domain 3 - communication, partnership and teamwork
Communication skills, Analysis of referral letters – content, Teaching and Training (educational supervisors OOH)

Domain 4 - Maintaining trust
Health

Example – prescribing habits

Collect 20 consecutive OOH consultations in which prescribing is an issue – this could be a conscious decision not to prescribe as well as issuing a prescription. Your reflections could include factors that make OOH prescribing difficult – e.g. strong analgesia or sedatives.

You can download the blank template here

You could use this exercise as a learning experience or a quality improvement exercise, where you may be able to demonstrate change by running a second cycle.

A completed example could look like this:-

SexAgeDiagnosisPrescribing choiceAllergies recorded?Why did you choose this course of action
F 3 Sore throat Penicillin V 125mg qid y Child was unwell some pus on tonsils
M 37 Back pain Co-codamol 8-500 n Acute back pain following lifting analgesia only
M 65 Diabetes with acute febrile illness and blood sugar of 23 Amoxycillin 250mg tid and bolus dose of Actrapid (10 units) y Had cold all week now coughing green phlegm – antibiotic in absence of chest signs – no ketones in urine – 10 units Actrapid only 10% of normal daily dose
F 44 Depression and insomnia Given diazepam 5 mg one tablet to see own doctor n Anxious and unable to keep still. Previous episode of depression. Currently no treatment
M 6 Sore throat Penicillin V 125mg qid y Mum pressurised for antibiotics – child feverish
F 60 Vomiting and diarrhoea for 4 days Buccastem and loperamide y Patient distressed no evidence fever but unable to tolerate even fluids. Made descision to prescribe Buccastem and pressurised into loperamide also “had them before”
F 32 Cough Advice only y Patient had 3 day history of non productive cough chest clear advice only
M 65 Chest pain No prescription y Short episode of possible angina, diabetic patient on aspirin as primary prevention. No previous history well and stable now. Advised to see own doctor for further evaluation – recall prn.
F 4 Otitis media Amoxycillin 125mg tid y Child in pain with fever mother wanted treatment
M 27 Dental abscess Metronidazole 400mg tid y Would normally have been triaged over to dentist but was casual attender at the base
F 19 Morning after pill request (Saturday am) Levonelle 2 y Appropriate prescription –appropriate OOH as 24 hours since event- also told to take the two at once – I picked this up on my recent contraception course
F 17 PV bleeding with pain Ponstan Forte y No evidence infective cause denies sexual activity usually has painful periods
M 12 Asthma Nebulised salbutamol then addition of beclomethasone – initially 250mg bd Peak flow meter y Patient on salbutamol alone – never had attack before. Nebulised as very frightened and made full recovery add steroid – written instructions given to represent as required
F 2 Runny nose and cough Amoxycillin 125mg tid y Had symptoms for 3 days with purulent nasal discharge – chest clear
F 56 Anxiety and depression Diazepam 2mg (20 only given) n This lady was very anxious I therefore prescribed short term diazepam in addition to the anti depressant her own GP prescribed yesterday   which should help long term
M 52 Back pain Co-dydramol 2 qid prn (50 tabs) n Acute on chronic back pain seems arthritic in origin
M 63 Testicular pain Ciproxin 250mg bd for 2 weeks y Appears to have epidymo-orchitis – treated and advised review by own GP in 3-4 days
F 4 Sore throat red eyes Chloramphenicol eye drops, amoxicillin 125mg tid y Sticky eye red and red throat
M 2 Sore throat Amoxicillin 125mg tid y Red throat brother of the patient above
F 78 Cough Amoxicillin 250mg tid y Chest clear but unwell

Learning points identified from these cases

I was struck by the fact that in these 20 cases I prescribed 10 courses of antibiotics. On looking at my case notes it seems that some of these prescriptions were probably unnecessary. I know that in my own practice (in hours) that I would not have prescribed so many, it may be a case of taking the easy option. I also used benzodiazepines twice, I am far more strict in hours.

The elderly patient with D&V was inappropriately given loperamide and this was entirely down to patient pressure.

I tended to ask about allergy status when prescribing antibiotics

Action to be taken/changes to be made

I can see from these consultations that I am probably more easily pressurised into prescribing out of hours. I will make a conscious effort to stop this.

I will read the protocol for nebuliser use in children and their aftercare as I was not entirely sure what to do in that case.

I need to check allergy status for all prescribing decisions.