Transcript 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
Mean mortality index
Teams save lives
Source:
Health Care Team
Effectiveness Project,
Aston University,
Birmingham, England
108
106
104
102
100
98
96
94
92
<40%
40-59%
60-79%
80-99%
%staff working in teams
100%
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
Hospital at Night: A competency based team
A&E
Medicine
Surgery
T&O
Anaesth
Consultant
SpR
SHO
Nursing
Nursing
Multiprofessional Team & Team Leader
A&E
Medicine
Surgery
T&O
Anaesth
Admin
AHP’s
Gain: new
competencies
Refined and
functional team
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
Whole Systems Working
Clinical Audit
Training
Clinical & Risk Governance
Competency Based Practice
Infrastructure
Handover & Communication
Clinical Leadership
Baseline Assessment Enablers
Organisational Leadership
Responses to Baseline Review - 2006
• 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
Intentions re HaN - 2006
Were Trusts planning to implement H@N?
12%
Trusts intending to HAN with
team in place
48%
Trusts intending to HAN with
no team in place (yet?)
Trusts not intending to HAN
with no team in place
40%
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
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
2006 Good Practice - Handover
• Developing electronic nursing handover
including eMEWs system
• In house electronic handover
• Nurse Clinicians leading handover
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
Support Services - 2006
% of Trusts surveyed
Are Trusts extending support services into the out
of hours period?
100
89
84
80
62
60
40
28
25
Cannulation
ECG - Weekend
20
0
Bed management
Radiology
Phlebotomy
Support service
Challenges identified in BR 2006
49
24
14
O
th
er
11
an
do
ve
r
16
H
100
90
80
70
60
50
40
30
20
10
0
Fi
na
nc
ia
l/s
tra
te
gi
c
C
lin
ic
al
bu
A
da
y
in
pt
in
g
H
A
N
m
od
el
% of Trusts
What challenges are Trusts facing in
implementing H@N?
Recommendations to Trusts from BR 2006
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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
Whole System Approach
Draw work into Extended Day
Maximise
primary care
contribution
Workload at night
Reduce out of hours operating
Treat &
Transfer
www.hospitalatnight.nhs.uk
Where was the focus?
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Patient safety
Benefits to organisation
Training
Next steps
Benefits Realisation & Business Case 2007
Demonstrated the
• Clinical, safety and
productivity case for
change
• Financial, workforce and
economical case for
change
• Wider NHS Reconfiguration
opportunities
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
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
3
Non-compliant
48 hours 56 hours
2A
High intensity
2B
Low intensity
1A
EWTD 2009
High intensity
1B
Medium intensity
1C
Low intensity
40 hours
No out of hours
Basic
0%
20%
40%
50%
Banding supplement - % of basic salary
80%
100%
Deaths reduced at speciality ward level
H@N Introduced
HaN - International
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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
I
lo
gy
G
E
EN
T
nc
ol
og
y
ER
2004
2005
p
R
es
Pa
ed
s
Te
le
ct
iv
e
O
rth
o
T1
O
rth
o
T2
St
ro
ke
C
oT
E1
C
oT
E2
O
Va
sc
ul
ar
O
bG
yn
U
ro
G
25
Cardiac Arrests 2004 = n105
2005 = n 75 = 29% drop
20
15
10
5
0
Readmission and post-ICU death rate
PERT starts
18
16
1192 adm/yr
1304 adm/yr
24hr PERT
starts
1173 adm/yr
1152 adm/yr
14
12
10
8
6
4
118 pts
113 pts
121 pts
105 pts
2
1st 5 m
23.5
0
2001
2002
Avg. post ICU death rate for year
2003
2004
Avg readmission rate
2005
Handover : Medical trainees: PMETB 2007
No
H@N
An
organise
d
meeting
doctors
& nurses
None
Informal A phone An
call or
organis
email
ed
meeting
doctors
1.2%
44.4% 5.2%
32.0% 17.1%
2.0%
20.0% 5.5%
24.3% 48.2%
N=
3,993
H@N
N=
1,228
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
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
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
Maximising training
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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
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
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
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
Risks of poorly planned shift-work
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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
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
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
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
Recommendations
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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
H@N Messages
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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
The future for Hospital at Night
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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
Thank you