Report from IHI’s 19th Annual National Forum on Quality Improvement in Health Care, December 9-12, 2007, Orlando, Florida

This National Forum Workshop presentation describes innovative approaches to clinical handoffs, medical staff training, and the timing of procedures to deliver safe and reliable care to patients at night.

Presenters

• David Gozzard, MD, MBA, Medical Director, Conwy and Denbighshire NHS Trust, Wales, and Health Foundation/IHI Fellow
• Carol Haraden, PhD, Vice President, Institute for Healthcare Improvement

The Setting

• Conwy and Denbighshire NHS Trust (C&D Trust) is a health system in North Wales, UK, that provides inpatient and ambulatory care to approximately 200,000 people in the winter and 500,000 in the summer through a network of hospitals, health centers, and clinics.

The Situation

• Through their professional representative body, the British Medical Association (BMA), British physicians negotiated a reduction in work hours (56 hours or less a week) several years ago.

• The European government recently implemented restrictions on work hours for all workers in the European Union (EU) that will go into effect in 2009 (48 hours or less, averaged over a 17-week period) and will take precedence over the BMA-negotiated restrictions. The EU directive includes time asleep on call in the total hours worked in the week. The directive has reduced available physician hours in the UK and prompted a move from long continuous work hours (e.g., 24 or more hours) toward scheduled day or night shift work.

• The hospital at C&D Trust was one of the first in the UK to investigate the Hospital at Night program as a solution to address the change to shift work, the absolute reduction in doctor-hours, and the concern that care provided during off hours (i.e., nights, weekends, holidays) often is more fragmented than care provided during daytime hours.

The Solution

• First, the hospital gathered information about the type of work tasks conducted at night and found that:
  • A significant proportion of tasks performed by doctors at night (e.g., looking for lab results) could be redistributed to nonmedical staff.
  • Activity levels differed between the general medicine and the surgery units: there was little urgent general surgery activity.

• The hospital used these data to address two main goals:

1. Minimize the amount of work conducted during the night.
2. Minimize the proportion of night work conducted by doctors.

• To address the first goal, hospital staff began proactive planning for the sequelae of daytime events. Staff considered the medications and procedures more likely to cause issues at night and, whenever possible, changed the timing of these interventions to minimize workload for night staff. In some instances, the changes necessitated expansion of services provided during the day. For example, rather than filling the operating room (OR) schedules to capacity with planned cases, the hospital began leaving space in the OR schedule for emergency cases. Thus, the hospital is less likely to need to delay planned cases for emergencies and less likely to be performing overflow cases at night.

• The hospital used several other strategies to address its second goal: minimizing night work for doctors and physicians-in-training.
  • The hospital at C&D Trust created multidisciplinary house staff teams. The teams include physicians-in-training from anesthesiology, surgery, medicine, and orthopedics, but with scaled-down representation from each area compared with previous night coverage. Rather than having up to three tiers of resident staff of varying seniority for each medical and surgical specialty, the team includes a mixture of trainees with differing experience. However, the hospital ensures that the team as a whole can provide all needed services, meaning that at least one member of the team can perform the procedures or other specialized tasks that are required at night.
  • The hospital moved nonmedical tasks from doctors to other staff. The hospital assessed the tasks performed by the physicians-in-training and found that a significant proportion of the tasks (e.g., administering drugs, drawing blood, searching for results) could be performed by nonmedical staff.
  • More effective paging and call policies were implemented, such as having calls triaged through the senior night nurse.
  • Tasks that could be moved (e.g., routine surgery, routine evaluations) were shifted to daytime hours.
  • The hospital reduced replication of tasks by physicians, such as repetitive history taking and physical examinations on admission.

• The hospital found that communication, especially at key handoff times, was critically important to a successful change to shift work. The hospital improved communication among staff by:
  • Using SBAR (Situation-Background-Assessment-Recommendation) communication to ensure accurate handoff of information Beginning the process of shifting the focus of nursing and medical reports from a recitation of tasks completed or pending (e.g., medications given, labs drawn) to an assessment of potential risk level of the patient, based on the professional judgment of the staff member providing report
  • Beginning to use written reports that are discussed verbally, rather than relying solely on reports transmitted via taped recordings

• To allow for more efficient use of medical staff time, the hospital implemented the Modified Early Warning System (MEWS), which allows nursing staff to identify patients at risk based on vital signs, consciousness level, and recent urine output (see the two figures below).

MEWS Scoring at Conwy and Denbighshire

• In the past, when a nurse was concerned about a patient, he or she contacted a particular physician-in-training on a particular service. That physician would assess and treat the patient, but often within the confines of the service he or she represented. As a result of the use of multidisciplinary teams, MEWS, and other interventions, now when a nurse is concerned about a patient, he or she contacts the team and discusses the concerns using SBAR communication and the MEWS system. The team then evaluates the patient with a multidisciplinary perspective, providing a more complete evaluation and communicating more widely about the patient’s status and management plan.

The Results Thus Far

• Implementing the changes associated with the Hospital at Night program, the hospital has reduced the number of doctors working at night by 17 (excluding pediatrics and obstetrics, areas for which night coverage is still being addressed).

• Quantitative data, such as the number of calls to the Rapid Response Team and the number of cardiac arrests, are being collected to assess the effects of the project on patient safety. Preliminary data indicate that number of cardiac arrests has been greatly reduced since the initiation of the Hospital at Night program.

• Some nursing and medical staff feel that patients receive a higher quality of care at night, because of the tight communication among staff and the team structure.

• Anecdotally, it appears that medical staff order fewer ancillary services within the revised care system, possibly because the team structure facilitates communication regarding diagnosis and management between subspecialties and between senior and junior trainees, thus minimizing the “spray and pray” approach to technology use.

Lessons Learned

According to the presenters of this Workshop session, the key elements that led to successful implementation of the Hospital at Night program include:

• Establishing a service-wide infrastructure for planning and design of service (i.e., ensuring that front-line staff and physicians were included in the planning process)
• Using existing service knowledge and experience (i.e., encouraging project teams to elicit suggestions from front-line staff who work the evening and night shifts)
• Implementing a “bottom up” approach to determine the team model to be used at each site (i.e., using an analysis of case mix, typical clinical problems, and needed skills to guide decisions about the number and required skill level of night duty staff) 

Plans for the Future

The Conwy and Denbighshire NHS Trust plans for the future include:

• Extending the lessons of the Hospital at Night program into the daylight hours
• Gathering further data on metrics of patient safety (e.g., number of patient contacts at night, nature of these contacts, number of falls)
• Combining physician and nursing report forms into a single document to be used at handoffs
• Assessing the effects of reduced training hours on the career paths and experience level of physicians-in-training; considering the necessity of a year-long preceptorship
• Considering the need for a “competency passport” for physicians-in-training to facilitate planning of team composition as trainees travel from site to site

For More Information

View the PowerPoint presentation for this Forum Workshop session:

• The Hospital at Night Program Presentation

01/22/2008