Can We Make the Hospital a Safer Place at Night?

Opinion Article by Caroline Chapman, Nurse Consultant for Hospital at Night, Portsmouth Hospitals NHS Trust.
In the dead of night, when the rest of the world sleeps, ward nurses up and down the country are calling the Hospital at Night service. They may be looking for a technician to take a blood sample or calling for medical help as one of their patients suddenly deteriorates.

Hospital at Night started in 2005 as a way to address the shortened working week for junior doctors with the European Working Time Directive. Many trusts adopted the system, which involved moving away from every ward for itself to a pooled on call team to be used across the hospital.

At Portsmouth Hospitals NHS Trust we ran ours in a conventional way, relying on highly experienced, senior nurses to run a co-ordination centre. Ward nurses telephoned the co-ordinator who would triage the call and bleep the most relevant person.

It worked reasonably well but there were gaps. If I bleeped a doctor, I had no way of knowing if he or she was already busy. The ward nurses were left hanging on the telephone, waiting for a reply to the bleeps while the on call doctors could not tell whether the next bleep was an emergency or a more routine call so they were constantly interrupted. We felt there was potential for harm.

Common themes
When we looked at our adverse incidents at night we found this impression was true. There were common themes such as errors in communication, patients not being tracked, failure to escalate potentially serious situations and poor record keeping. Senior nurses like myself were largely deskbound by the need to be near a telephone, dealing with hundreds of calls per shift, rather than out and about supporting the wards and giving direct patient care.

We knew safety was high on the agenda - Don Berwick's report on patient safety was fresh in our minds - so we set about modernising our Hospital at Night programme to improve safety and quality of care. Using a grant from NHS England's Nursing Technology Fund, we invested in an electronic task management system with the aim of improving safety.

It works like this. Ward nurses requiring support enter a request onto the online software. Hospital at Night co-ordinator/practitioners receive the request electronically via a PC or tablet, triage for urgency and skill required and assign the task to the relevant on call doctor, nurse or technician with a single click.

As a co-ordinator/practitioner, I can now see in real-time who is on duty, their skill set, where they are and how busy they are. I can allocate the best person to the task and if something urgent comes in, I can divert the most senior and experienced person to deal with it.

Our on call doctors no longer get bleeps but an alert on their mobile device with details of the task. They can see immediately if it is an urgent call and do not need to constantly interrupt their work to answer bleeps.

A safer system
Implementing our new system involved significant change to our processes but even so we found staff adapted quickly and easily.

The nurses were surprised at how quickly they got a response, with a member of the out of hours team on the spot sometimes within as little as five minutes. The doctors were keen on the safety aspects of the system and being able to see a detailed list of patients and how serious the needs are.

Our new Nervecentre Hospital at Night system is very pro-nursing. It puts nurses at the centre of improving patient safety. Our co-ordinators, who are very senior and experienced staff, are no longer tied to a desk answering the phone and chasing bleeps. They are now able to oversee the system while working on the wards. They are out there, seeing patients and leading nursing on the wards and have time to train in advanced skills such as independent prescribing.

In the first year we halved the number of red and amber incidents, in which patients were put at severe or moderate risk of harm, and we have had not a single adverse death at night. This is both because doctors can attend to the most urgent needs first and because ward nurses are no longer waiting by the phone when they need support. Now that nurses can stay with patients we have found there is less risk of falls, for example.

Hard data
With a proper audit trail and aggregated management information, we now know what our on call clinicians are doing at night. We can tell the deanery about the hours junior doctors have worked and the tasks undertaken. We can review incidents in much more detail.

We now know, for example, that technicians and not our on call doctors are inserting cannulas and taking bloods. We have demonstrated to the Trust the level of support required to operate more safely at night and have since employed an additional technician as a result.

We hoped we would improve safety in the hospital at night and we have achieved this. We did not realise just how many other benefits we would see. Now we are keen to make more use of the electronic task management system by extending it to the weekend day time.

This was a clinical transformation, underpinned by information technology. It has taken off so well because it not only improves safety but also it makes clinicians' work easier. Ten years on from the start of Hospital at Night, we have found a safer way to care for our patients. We think there are lessons in our experience for other trusts that agree it's time to modernise hospital at night.

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