Prioritising Jobs and Tasks

Introduction

This article will focus on common jobs and tasks you will likely encounter as a doctor and how to prioritise these appropriately. 

How do I receive jobs?

On-call shifts

How you get jobs when ‘on call’ will vary across different hospitals. They may take the form of notifications via an application on a handheld device (such as Nervecentre), or you may get jobs by receiving bleeps, pages or phone calls. 

If you are receiving jobs via a bleep or phone call, it is important to write the job down so that you don’t forget it if you are distracted or have to attend to another more urgent job in the interim. Make sure that you keep your jobs list safe!

For more information on on-call shifts, see our guides to the medical on-call shift and surgical on-call shift.

Normal working day

If you are working between 8am – 5pm, then this is a normal working day. Whether working on the wards, in the Emergency Department or in General Practice, you will likely see and review multiple patients who need various tasks completed for their ongoing care. 

Often, you cannot do jobs straight away, so it is essential that you make a list of jobs as you go along. If you’re on a consultant or registrar-led ward round where many patients are seen, you may then decide to divide the jobs equally between the junior team working on the ward after the ward round has finished. 

The jobs list

We’ve already highlighted the importance of keeping a list of jobs for patients as you go along, to ensure none are missed.

This list tends to be handwritten, but it depends on the person/people using it as to where it is written so that it is most useful. It may be on a printed handover sheet of the ward’s patients, or a book may be kept by the junior team that has a daily jobs list on each new page. The benefit of the latter is that jobs that can’t be completed the previous day can be easily transferred over rather than being disposed of with the list and forgotten. 

Who will give me jobs? 

On-call

When you’re on call, jobs for patients generally come from the nursing team caring for the patient.

There may be circumstances where you are given a job by another team member, such as an out-of-hours coordinator asking you to review a patient or a registrar asking you to do some bloods for a sick patient.

Normal working day

On a day shift, jobs are likely to come from a mixture of the senior medical team (consultants and registrars), nursing team or you may generate your own jobs if you are carrying out a junior-led ward round.

Types of jobs

There are several different jobs that you may be expected to do. The list below covers the most common jobs but is not exhaustive. These jobs are generated on both normal working days and on on-call shifts.

We also have a detailed guide covering common medical on-call scenarios and jobs.

Reviewing a patient

You can be asked to review a patient for various reasons, including during a day shift or an on-call shift.

The main reasons for being asked to review a patient are a high NEWS (National Early Warning Score) due to patient deterioration or another change in their clinical picture (such as new confusion or agitation). Often, this job will be a high priority, especially if you are being asked to see a patient due to a high NEWS score.

Remember that this job may generate further jobs, such as venepuncture, cannulation, blood gases or imaging, which must also be actioned. Patient reviews are one of the most common jobs, whilst having the largest variation in what the job requires!

Prescribing medications

You can be asked to prescribe wide range of medications for patients. They can be broadly categorised into prescription of therapeutic medication, prescription of intravenous (IV) fluids, and prescription of blood products (i.e. red blood cells or platelets).

The urgency of the prescription will depend on what you are prescribing: a critical medication (such as Parkinson’s or anti-epileptic drugs) that is due a dose is likely more urgent than prescribing a laxative for a patient.

When asked to prescribe IV fluids, ensure you have assessed the patient’s fluid status and thought about whether they really need those fluids – most patients don’t need IV fluids prescribing at 3am!

When deciding how urgent a prescription is, consider the likely outcomes if you attend to the job immediately, in a few hours, or by the end of shift. For example, a laxative can likely wait, whilst a beta-blocker for a patient with atrial fibrillation with a rapid ventricular response or pain relief for a patient with severe pain cannot.

Reviewing blood tests

This is as it sounds: reviewing the results of blood tests taken earlier and then acting on any abnormalities you may find.

Ensure you know why the blood tests were taken, as this plays a part in your clinical interpretation of the results. Generally, the results you are asked to interpret are taken for one of two reasons: either they are taken as ‘routine’ bloods, or they are urgent bloods taken for an unwell patient to assess pathology.

Examples of routine bloods include U&Es taken for a patient on diuretic treatment or an INR to allow warfarin dosing, whilst urgent bloods include a troponin level taken for a patient with chest pain or a haemoglobin level for a patient with suspected bleeding.

If any change in management is required due to the blood results, ensure that this is documented in the medical notes.

Reviewing imaging resuls

Imaging review tasks include reviewing and acting on the reports of any imaging a patient has had, including ultrasounds, X-ray, CT and MRI scans. Again, it is important to know the indication for the imaging and appropriately escalate any findings to senior team members. 

Common imaging reviews you may be asked to complete are CT head scans for patients with altered GCS or head injuries after a fall or chest X-rays for patients with new breathing difficulties.

Verification of death

When verifying (confirming) death, it is important to know whether it is expected and check that a valid DNACPR is in the notes.

If you’re working on a night shift, make sure that you confirm the death before midnight if you receive the task before midnight, as the patient has not legally died until you confirm the death. A delay could result in an altered date of death, which could be confusing or distressing for family members.

Venepuncture

Generally, routine venepuncture will be undertaken by phlebotomists (during the day) or clinical support workers with an out-of-hours team. However, you may be asked to assist with more difficult venepuncture or when there is no phlebotomist or clinical support worker.

When prioritising venepuncture, you need to establish the reason for venepuncture being requested. It may be time-sensitive (such as taking a drug level), time-critical (such as taking a troponin for a patient with chest pain) or for routine monitoring (such as U&Es for a patient on diuretic treatment).

Cannula insertion

The same guidance applies as for venepuncture. The urgency with which a cannula needs to be inserted is dependent on the reason why a cannula is needed: it may be for critical medication, for maintenance fluids, or for medication due in a few hours.

Catheterisation

You’ll most commonly be asked to insert male catheters, although some team members can insert both male and female catheters.

The most common reasons for catheter insertion are new urinary retention, accurate fluid balance or a routine catheter change.

Generally, catheters will be of middling priority. However, they should not be delayed when a patient is experiencing pain due to waiting for a catheter (in the case of urinary retention).

Insertion of an NG tube

As with a lot of the jobs you are doing, make sure you know why you are being asked to insert an NG tube – is it for feeding, administration of medication, or for decompression in suspected bowel obstruction?

Ensure you also know your hospital policy for inserting NG tubes, as some hospitals only allow staff members who have completed a series of mandatory training to insert feeding NG tubes. 

Family or patient discussion

You may be asked to speak to a patient or their family members for various reasons, including updating them on their current diagnosis or management plan, explaining a treatment or procedure, or potentially having more difficult discussions where treatment is not working as expected or resuscitation discussions.

Try to gather as much information as possible from the patient’s notes before having these discussions, and if you’re not sure, plan how you might get additional information and get back to them (such as speaking to your registrar/consultant). 

During your day shift, you should complete patient and family discussions, as routine updates are not expected to fall to the on-call team.

While on call, there may have to be discussions where a patient has unexpectedly deteriorated, but due to the overall workload of the team there is often no capacity for discussions beyond this.

Clerking

Clerking jobs are generated in admissions areas (i.e. medical or surgical assessment units), or areas where patients are directly admitted by paramedics or from the emergency department, including stroke units for thrombolysis or coronary care units for PPCI.

Different units often have their own format for how this clerking is carried out. Still, you can generally expect to take a history and examine the patient, prescribe their regular medications and any additional medications required (usually documented by the senior clinician who has accepted the patient to the admissions area), and request any ongoing investigations (again, usually highlighted by a senior clinician).

ECG interpretation

ECG interpretation is a common job, both during working hours and when on-call. Before interpreting the ECG, make sure you know why that ECG was taken: for example, was it done due to the patient having chest pain, because of hyperkalaemia or a routine admission ECG? This will potentially change the task’s priority and your interpretation of the ECG.

When interpreting an ECG, make sure that any changes to the management of the patient due to the ECG are documented in the medical notes.

It is also good practice to document your interpretation of the ECG and ensure that the ECG is filed correctly in the medical notes.

Advice

Usually, this request is from nursing staff and will be queries that generally do not need an immediate answer but should be attended to during your shift. Advice may be around medication, clarification of management plans or entries in the medical notes.

Completion of discharge letter

Writing a discharge letter is a common job during the day, but this task should not be routinely completed out of hours.

Discharge letters for inpatients are best completed by the team primarily responsible for their care to ensure continuity and that follow-up is organised appropriately.

That is not to say that you won’t, on occasion, be asked to complete a discharge letter out of hours (for example, if there is an urgent need for further inpatient beds), but make sure that the medical notes state that the patient is ready to be discharged from hospital.

If you’re unsure whether a patient is well enough to go home, or there are other reasons that they are not ready for home – such as awaiting a package of care – make sure you speak to a senior about this to clarify.

Falls assessment

When patients fall in hospital they need to be urgently assessed for injuries. Some hospitals will have a proforma that needs to be completed for a patient after they have fallen, whilst at other hospitals an entry in the medical notes will be enough.

Every patient who falls needs to be assessed for why they fell in the first place, which includes a review of their medication (looking for antihypertensives/sedatives in particular) and any preceding symptoms (such as chest pain or dizziness).

The mechanism of the fall should also be established: was this due to an environmental reason such as slipping on the floor, or due to syncope? Before the patient is moved, you will then need to assess for head injuries and any evidence of neurological changes, before assessing for any other injuries and any systemic abnormalities.

Once your findings are documented, you may need to request further investigations, such as a CT scan of the head or X-rays for suspected fractures.

For more information on reviewing a patient who has fallen, see our guide to common medical on-call jobs.

Referral to specialty 

Generally, you should expect to do this when working on a day shift, but it is less common on an on-call shift. On your day shift it is best to sort out referrals as early as possible, as it increases the possibility of your patient being seen on the same day.

When on-call, the need to refer a patient to a specialist is often due to change in their clinical condition or as a result of investigations. Sometimes medical notes will have clear criteria for referring to a specialty (i.e. if CT head shows intracranial bleed, refer to neurosurgeons), but if you are unsure then speak to a senior member of the team before referring. 

How do I prioritise jobs?

This is often one of the most difficult parts of starting on-call work as a doctor, as it is a skill honed with experience. Strategies you can use are outlined in the following part of the article.

In some hospitals, systems may be in place to help you prioritise jobs. For example, some IT systems allow jobs to be submitted with a red, amber or green tag, which is then reviewed by an out-of-hours team coordinator and allocated to an appropriate doctor. 

Red jobs are the highest priority (should be completed within an hour), whilst green jobs are the lowest priority (ideally to be completed by the end of the shift). If allocated a red job, you would be expected to move on to that job as soon as you finish what you’re doing.

Even if you don’t have IT systems that prioritise jobs for you, you can apply this traffic light system to prioritise jobs as you receive them.

The traffic light system

Red 

Red jobs could include patients with a high NEWS score, some abnormal blood test results (such as hyperkalaemia, significantly elevated troponin and D-dimer), agitated patients who are a risk to themselves, staff or other patients, falls assessments or prescribing of critical medication.

Amber

Amber jobs would include reviews of patients with a change in the clinical picture but not imminently deteriorating, clerking, investigation reviews, cannula insertion or venepuncture, catheterisation, verification of death or insertion of an NG tube. Discussions with family members or patients may fall into this category, depending on the nature of the discussion, i.e., a discussion about a deteriorating patient. 

Green

Green jobs would include discharge letters, some family discussions, and routine medication prescribing (excluding critical medications).

Principles of prioritising

When you receive a job, you need to consider what the outcomes for that job will be depending on when you complete it.

For example, when receiving a task to review a patient with chest pain, what are the outcomes if I review them in an hour? What if I leave it for 4 hours to review them? How about if I leave it until the end of my shift? Asking these questions will generally allow the task’s priority to be revealed – obviously, you will try to see the patient with chest pain as soon as possible!

A general order of job priorities is shown below, although bear in mind some jobs may go up or down depending on further details of the job (as detailed in the descriptions above).

Emergency calls

Some jobs require you to safely stop whatever you are doing and attend immediately to them, which are 2222 or emergency calls.

If you are carrying an emergency/crash bleep, generally, you will hear an alarm tone and spoken instructions of what type of call it is (i.e. cardiac arrest) and the location. You should make your way there as soon as possible, although if you are in the middle of a procedure, you should try to finish or stop this safely first.

Conclusion

There are multiple tasks that you may be asked to complete whilst at work, although the way you receive them is likely to be different dependent on whether you are on-call or on a day shift.

Prioritising tasks appropriately takes experience, but unwell patients will always be at the top of your list of tasks.