Hospital at Night – meeting the challenge of the WTR Professor Wendy Reid Consultant Gynaecologist Postgraduate Dean of Medicine, London Vice President RCOG

What was the challenge? To provide safe medical care at night and weekends within WTR and New Deal contract To minimise the impact of out of hours work on junior doctors so that they achieve their training targets (training happens in day time with supervision) Reducing hours requires unpopular shift work not ‘on-call’ rotas for majority

Risks of poorly planned shift-work More handovers, potentially 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 no one 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

Service and Training balance

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

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

Multiprofessional Team & Team Leader Consultant SpR SHO MedicineSurgeryT&O Anaesth A&E Nursing MedicineSurgeryT&O Anaesth A&E Nursing Admin Refined and functional team Gain: new competencies Hospital at Night: A competency based team AHP’s

What is Hospital at Night? Consists of one or more multi-professional teams Full range of skills and competences Ability to meet the immediate and urgent needs to patients. Can call in specialist expertise when the patient needs it. Co-ordinated approach, structured handover Many different models now in place, extended to 24/7 care

What is Hospital at Night? Consists of one or more multi-professional teams Full range of skills and competences Ability to meet the immediate and urgent needs to patients. Can call in specialist expertise when the patient needs it. Co-ordinated approach, structured handover Many different models now in place, extended to 24/7 care

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

HaN evidence

What drives implementation of HaN? Improved patient safety Efficient use of staff – junior doctors in particular Better use of facilities Cost effective e.g. Reduced bed occupancy Retention of senior nursing staff Supports day time elective activity

Cardiac Arrests : 2004 = n = n 75 = 29% drop

Readmission and post-ICU death rate Avg. post ICU death rate for year 1152 adm/yr 1192 adm/yr 1173 adm/yr 24hr PERT starts Avg readmission rate PERT starts 118 pts 113 pts 121 pts 105 pts 1 st 5 m 23.5 % of admissions 1304 adm/yr

HaN Safety Evidence

WTR implementation: What was positive? Team work – since 2004: Hospital at Night, > 70% acute hospitals in England Innovative ways of working e.g. Elective/Emergency split, 24/7 teams Some specialties working towards consultant delivered service e.g. Obstetrics, Paediatrics Central funding from government – total £310 million, included targeted funds for ‘trained doctor solutions’ in Paediatrics and ObsGyn (£50 million) Hospitals and regions piloting 48 hour solutions Junior Doctors consistently voted for WTD at BMA The Temple review of training in 48 hours EWTD

System Change – Hospital at Night Core Standards London Redesigning the training experience to maximise patient safety as well as education NHSL 2012

London NHS audit of HaN 2010 & 2011 Against core standards benchmarking All acute admitting hospitals Excluded Obstetrics, Paediatrics, Psychiatry and single specialty sites Included trainee doctor satisfaction data from GMC survey All hospitals improved against the standards – areas of most improvement were handover, links to daytime teams, early discharge of acute admissions

The New NHS Culture © 2009 Copyright Salisbury NHS Foundation Trust Author: Debbie Dupont

Changing the NHS Culture

Why do doctors in training need to be protected ? “Properly planned and carefully conducted medical education is the foundation of a comprehensive health service.” (The Goodenough Report, 1944)

Tired doctors matter Warwick Research showed clinical errors reduced by a third following 48-hour week and shorter shifts. (F.P. Cappuccio et al) Reduced shift durations (from 24 to 16 hours) for emergency docs in New York reduced mortality and improved doctors work / life balance. Doctors working for 24 hours double their risk of being in car accidents. [Barger, Cade Ayas, Cronin et al. NE Journal Med, 2005.] International research shows working for 24 hours equates to drink driving. [Williamson, Feyer - Occup Environ Med 2000; 57: ]

Doctors working h straight: make 36% more serious medical errors make 6 times more serious diagnostic errors get ‘needlestick’ injuries twice as often overnight report nearly 4 times more fatigue-related errors when working h shifts/month report 300% more fatal adverse events had 2.3 times more actual crashes and 6 time more ‘near- crashes’ when driving home after work Lockley et al., N Engl J Med 2004; Landrigan et al., N Engl J Med 2004; Barger et al., N Eng J Med 2005; Ayas et al., JAMA 2006; Barger et al., PLoS Med 2006; Harvard Work Hours Health and Safety Group

Relationship between service and training When clinical service is so dependent on Trainees the relationship between service and training may be unsafe and impacts on delivery of good training. Occurs when trainees are:  un or under-supervised  spending large proportion of time on inappropriate tasks  working in a dysfunctional team

Risks to HaN Rota gaps – absence of trainees: maternity leave, out of training time, sickness Shift length limits make handover difficult – shift lengths of hours possibly more effective SiMAP means less intense specialties lose daytime activity even though doctors mostly sleep at night Compensatory rest extremely difficult as destroys integrity of team Smaller units – too frequent nights, pressure on middle-grade physician and anaesthetists Surgery unless core trainees work across specialities Obstetrics Paediatrics Psychiatry

What makes development of HaN 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 Challenge of rural sites Leadership: Royal Colleges, professional groups

Hospital at Night is: A proven approach to safer patient care and protected training time in acute hospitals Not a universal solution to implementation of WTR Not functional if changes in day and evening services do not support out of hours work e.g. access to diagnostics Able to improve efficiency

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

Thank you