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Hospital at Night

Hospital at Night. Wendy Reid National Clinical Lead, HaN National Clinical Advisor, Department of Health, European Working Time Directive Postgraduate Dean of Medicine, London. What is the ‘Hospital at Night’?. Team approach to maximise patient safety out of hours and protect training time.

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Hospital at Night

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  1. Hospital at Night Wendy Reid National Clinical Lead, HaN National Clinical Advisor, Department of Health, European Working Time Directive Postgraduate Dean of Medicine, London

  2. What is the ‘Hospital at Night’? • Team approach to maximise patient safety out of hours and protect training time

  3. Teams save lives Mean mortality index Source: Health Care Team Effectiveness Project, Aston University, Birmingham, England %staff working in teams

  4. H@N Beginnings • To protect training time by minimising out of hours cover • Reduce doctors sleeping in, doing unnecessary tasks, ‘wasting’ hours • Drivers for change: EWTD 2004, salary costs relating to New Deal for junior doctors • Clinicians will only engage if system change is good for patients • Evidence of unsafe care in previous rotas

  5. Hospital at Night: A competency based team Anaesth A&E Medicine Surgery T&O Consultant SpR SHO Nursing Multiprofessional Team & Team Leader Nursing Anaesth A&E Medicine Surgery T&O Admin AHP’s Refined and functional team Gain:new competencies

  6. H@N: developments since 2004 • Baseline reviews: July 2006, 2008 England • Assessed implementation of H@N in trusts in England against 9 enablers • ‘Key challenges’ identified 2006 • ‘Best practice’ identified 2006-7 • Pilots funded by Skills for Health, NWP – extension of H@N, 24/7

  7. Baseline Assessment Enablers Organisational Leadership Clinical Leadership Handover & Communication Infrastructure Competency Based Practice Clinical & Risk Governance Training Clinical Audit Whole Systems Working

  8. 97 Trusts 83 Acute 3 PCT 7 Mental Health 4 Specialist (8 FTs) 53 Urban (56%) 24 Suburban (26%) 17 Rural (18%) n=94 Type 40% (38) Non-Teaching 60% (57) Teaching n=95 Responses to Baseline Review - 2006

  9. Intentions re HaN - 2006

  10. Findings – example Support from executive and medical directors and dedicated project management crucial • 93% of Trusts stated they had an Executive and Medical Director sponsoring • 7% - did not have executive support, most also did not have implementation group or clinical champion There is a clear linkage of delivery of H@N to Executive & Clinical leadership

  11. Findings – example: patient safety The majority of Trusts have risk scoring systems in place • Over 50% are of Trusts using PAR/MEWS scoring systems to prioritise patients • 64% are trialling protocols to determine how long patients can wait for assessment • 64% have some degree of integration to CCOT

  12. 2006 Good Practice - Handover • Developing electronic nursing handover including eMEWs system • In house electronic handover • Nurse Clinicians leading handover

  13. Good Practice reported in BR 2006 • Care Pathway Simulation using Discrete Event Simulation (DES) • Medical support team • Wireless system • CCOT involvement • Critical clinical incidents reduced • Bleep policy • Competency workbook • H@ N team placements for student nurses • Doctors assistants as part of H@N team

  14. Support Services - 2006

  15. Challenges identified in BR 2006

  16. Recommendations to Trusts from BR 2006 • Review ‘gap’ for 2009 • Explore financial benefits of H@N • Review leadership and project management • Review and develop competences of team including leadership • Risk assessment processes • Link plans for 2009 with ‘MMC’ as well as WTD

  17. Whole System Approach Draw work into Extended Day Maximise primary care contribution Workload at night Treat & Transfer Reduce out of hours operating

  18. www.hospitalatnight.nhs.uk

  19. Where was the focus? • Patient safety • Benefits to organisation • Training • Next steps

  20. Benefits Realisation & Business Case 2007 Demonstrated the • Clinical, safety and productivity case for change • Financial, workforce and economical case for change • Wider NHS Re-configuration opportunities

  21. H@N: Benefits realisation • Patient & Safety Focussed • Better Clinical Outcomes • Reduction in Mortality • Homerton Hospital & South Devon NHS Trust • Reduction in Cardiac Arrests and better survival rates • Reduction in Clinical severity of clinical incidents • Length of Stay • Reduction in LOS • St. Thomas’ have seen a 20% in LOS • Reduction in admission & readmission to ITU • Other Clinical • Patients’ experience improved

  22. Financial • Cash releasing element by applying rota’s differently • £380,000 (Potential 2006/7 figures) • Set up costs for H@N Team £110,000- 300,000

  23. Deaths reduced at speciality ward level H@N Introduced

  24. HaN - International • Hong Kong • USA • Australia • New Zealand • EU – (work with new member states CEEP) • All Western health systems looking for increased safety, improved retention and productivity of workforce, work-life balance

  25. Cardiac Arrests 2004 = n105 2005 = n 75 = 29% drop

  26. 24hr PERT starts Readmission and post-ICU death rate PERT starts 18 1192 adm/yr 1173 adm/yr 16 1304 adm/yr 1152 adm/yr 14 12 10 121 pts % of admissions 113 pts 118 pts 105 pts 8 6 1st 5 m 23.5 4 2 0 2001 2002 2003 2004 2005 Avg readmission rate Avg. post ICU death rate for year

  27. Handover : Medical trainees: PMETB 2007

  28. HaN - Impact on workforce • Medical • Education protected as fewer nights mean more daytime exposure • Increased supervision when working as part of the team • Supported as part of a multi-professional team • Clinically lead decisions for the whole team (SpR/ST3+) • Nursing • Increased retention of senior nurses • Role progression and enhancement • Lead the team from and organisational and Supported throughout the 24:7 period • coordination of care aspect

  29. The Challenges for trainers: • New curricula – generally shortened training time, focus more on specialty skills rather than acute care skills • Explicit competencies, require supervision and assessment • Risk of reduction in daytime shifts as reduction in hours leads to increased number of night time shifts • Reduced trainer/trainee contact time • Increased time needed for consultant supervision, assessments, completion of log books etc

  30. The context for trainers in a 48 hour week • Service targets – focus on productivity and efficiency • Increasing ‘out of hours’ work load for consultants • Changes in service ‘landscape’ – shift from secondary to community care provision • Delivery of workplace based assessments • Requirement for trainers to meet PMETB standards • Revalidation

  31. Maximising training • Maximise daytime work (H@N model) • Use all clinical episodes for training • ‘modularise’ training opportunities • Use modern technology: e-learning, simulation • Ensure education and training are a core belief and a core activity for the organisation with leadership and board level responsibility

  32. Training and WTD • 85% of acute trusts have processes in place to assess the impact of European Working Time Directive (EWTD 2009) compliance on medical education requirements. • 95% of acute trusts reported that they are developing a solution to meeting medical education requirements whilst implementing EWTD 2009. • However, anxiety as trust information from managers who may not realise the training implications if change is too late i.e. July 2009

  33. HaN – effects on doctors in training • Helps reduce out of hours work • Increases team working skills • Focus on handover – educational if consultant present • Protects day time training • Maintains generic ‘doctoring’ skills • Develops training opportunities at night • Develops leadership skills

  34. H@N and shift working • WTD makes shifts inevitable for most acute services • 7 nights too many, split week 3/4 safer (C Zeisler, NJM) • H@N reduces numbers of shifts for individuals • Team approach means all patients cared for by single team with ‘hub and spoke’ as necessary • H@N formalises handover • H@N encourages joint medical and nursing handover

  35. Risks of poorly planned shift-work • More handovers, more risk to patients • Less continuity of care - and of education • Separation of trainers from trainees • Senior leadership at night often fractured across ‘firms’ and not clear of the role • Destruction of team-working • Night shifts yield sparse training or experience for surgeons • Frustration of trainees removed from curriculum-relevant work, risks emergency care becoming a problem for training not an integral part of training • Stressful, increased sickness etc

  36. HaN and WTD 2009 • HaN requires good professional relationships • BMA supports WTD, (2/3 trainees compliant Sep 2008) • NPSA supports HaN • NICE guidelines on safe clinical practice reference HaN • Without multi professional, cross specialty team work 48 hours is unachievable

  37. EWTD National Pilots Programme • DH Commissioned Skills for Health Workforce Projects Team to lead national EWTD 2009 programme. • WPT have sponsored about 30 – clinically led- EWTD pilots and the Hospital @ Night, with London Deanery. • Virtually all pilots now completed. Vast majority show that creative solutions can be implemented to support patient care and clinical training. • Evaluation of programme to be published soon. Lots of help available.www.healthcareworkforce.nhs.uk

  38. What makes development of H@N difficult? • Specialty and Professional protectionism • Poor rota design reducing direct training time • Developing a ‘night safe practitioner’ is not something all specialties will contribute to • Night work becomes a silo for non consultant career doctors • Other agendas: e.g. PBR • Challenge of rural sites • Leadership: no ownership from Royal Colleges, support from union for reduced hours but not necessarily HaN

  39. Recommendations • Look at total workforce, not just junior doctors • Negotiate with all unions, not just BMA • Use local expertise to lead but learn from others • Re-align workforce with ‘MMC’, MNC, Primary care etc, find the ‘synergy’ • Develop National standards with Royal Colleges • Incorporate standards into training curricula for all health care professionals • Define leadership roles and train for them • Refine T&Cs for ‘new’ roles

  40. H@N Messages • Safer patient care equals safer training • Tired staff are unsafe • WTD and HaN linked • HaN is not just about hours and rotas • Bad Teamwork is worse than no teamwork at all • Leadership is not by doctors necessarily • There is a lot of evidence ‘out there’ to help develop safe systems and define competencies

  41. The future for Hospital at Night • The 24 hour hospital • Improved care of the acutely ill patient • Competency based approach • Improved training in teamwork • Improved leadership training • Ensuring the right person, at the right time available for the patient 24/7

  42. Thank you

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