London’s “Hospital at Night”
Hospitals in the United Kingdom are still adapting to the European Union’s Work Time Directive that in 2004 drastically reduced the number of hours physicians in training can work. Meanwhile, many US residency programs are seeking ways to reduce resident hours to limits that scientific evidence indicates are safer than what ACGME currently allows. Reducing consecutive hours to 12-16, while maintaining and improving work productivity, patient care, and resident education is no easy task. London’s Hospital at Night is an innovative model that strives to do just that.
The Hospital at Night pilot program was designed and introduced by the London Deanery, which trains the largest number of doctors in the UK, as a way to accommodate the 2004 Work Time Directive. The Directive mandated a marked change from the previous standards on resident hours; weekly in-hospital hours had to be reduced from about 72 to 56, and shifts could be no longer than 13 consecutive hours. Faced with this transition, the London Deanery decided to reexamine how they provided around-the-clock patient care in their hospitals.
What Goes On At Night?
One time of day in the hospital that caught their attention was the night. They observed that the hospital generally quiets down by the late evening, except for the care of the sickest patients, but that every service still had someone in the house “watching their patch.” Even so, their statistics showed that adverse patient care events tended to happen at night.
Taking a closer look at this phenomenon, the London Deanery made the following discoveries about the way things were managed in the late hours of the night:
- While it is always necessary to have specialists vital to instant response situations in the house, having too many doctors in non-EM specialties negatively affected after-hours patient care because it “ties up people in the wrong place doing the wrong jobs at the wrong time,” in the words of Dr. Wendy Reid, a practicing Ob-Gyn who oversees the Hospital at Night effort in the UK.
- Communication between nurses, residents, and attendings was poor. There was a hierarchical progress of paging in which the most junior residents were always paged first for jobs large and small, with several subsequent calls up the chain of command until an attending was consulted, costing precious time in urgent situations.
- The majority of after-hours work at the hospital was of little educational value to the training of better physicians.
It Takes a Team
From these observations the Hospital at Night project took hold, with an emphasis on teamwork. Hospital at Night operates as a multi-disciplinary team of medical and surgical residents, headed by a Clinical Site Manager, usually an experienced critical care nurse. One way this teamwork is expressed is in the handoffs that occur every 12 hours (distinct from the normal handoffs that occur within the medical and surgical teams). Each evening at about 9 PM, the departing day team of medical and surgical residents meets with the Hospital at Night team coming on duty to identify the patients who are the sickest or are of most concern. Again in the morning, the Hospital at Night team has a similar meeting with the incoming day team before going off duty.
Teamwork is also involved in Hospital at Night’s “No Bleep” policy, which seeks to limit late night paging. Under Hospital at Night, the nurse team leader filters all calls. If he or she can answer the question, they will and if it’s a request for service, like an IV that can’t wait until morning, they will do it. If the call requires a physician, the team leader will contact the most appropriate level of medic on duty – the more serious the situation, the more senior the doctor.
With such an emphasis on teamwork, it is not surprising that many report that utilizing the Hospital at Night model has led to stronger collegial relationships between doctors and nurses on staff. “It’s led to a much greater respect,” said Dr. Diana Hamilton-Fairley, a co-director of Hospital at Night at her hospital in Central London, “and a much healthier, professional relationship.”
Thus far Hospital at Night has received positive reviews from its participants. “Nurses on the floors feel supported [by the nurse team leader],” said Dr. Reid of the program’s success, “and physicians can get their work done, no longer constantly interrupted by pages.”
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To read CIR’s full report on Hospital at Night, click here.