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Making hospitals safer at night

A new Hospital at Night electronic management system is improving patient safety and giving nurses more time for direct patient care, says nurse consultant Caroline Chapman. 
Night nursing

A new Hospital at Night electronic management system is improving patient safety and giving nurses more time for direct patient care, says nurse consultant Caroline Chapman

In the middle of the night, when the rest of the world is asleep, 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 a patient suddenly deteriorates.

Picture: iStock

Hospital at Night started in 2005 as a way to address the shortened working week for junior doctors under 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, highly experienced senior nurses ran a coordination centre. Ward

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A new Hospital at Night electronic management system is improving patient safety and giving nurses more time for direct patient care, says nurse consultant Caroline Chapman 

 

In the middle of the night, when the rest of the world is asleep, 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 a patient suddenly deteriorates. 

Night nursing
Picture: iStock

Hospital at Night started in 2005 as a way to address the shortened working week for junior doctors under 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, highly experienced senior nurses ran a coordination centre. Ward nurses would telephone the coordinator, who would triage the call and bleep the most relevant person. 

Constant interruption

Although this worked reasonably well, there were issues. If I bleeped a doctor, I had no way of knowing if he or she was already busy. Ward nurses were left waiting for a reply to their bleeps, while the on call doctors could not tell whether the next bleep was an emergency or a more routine call. They were constantly interrupted and we felt there was potential for harm.

When we looked at our adverse incidents at night, we found this was true. Common themes included communication errors, patients not being tracked, failure to escalate potentially serious situations and poor record-keeping. 

Senior nurses like myself were largely desk-bound by the need to be near a telephone, dealing with hundreds of calls per shift rather than out and about supporting the wards and delivering direct patient care. 

Safer system

In July 2014 we decided to modernise our Hospital at Night programme to improve patient safety and care quality. With a grant from NHS England’s Nursing Technology Fund, we invested in an electronic task management system, known as the Nervecentre (see below). 

Staff adapted quickly and easily to the new system, even though it involved significant changes to our processes. Nurses were surprised at how quickly they got a response – a member of the out of hours team was on the spot sometimes within as little as 5 minutes 

Our new Nervecentre Hospital at Night system puts nurses at the centre of improving patient safety. It is very pro-nursing, with senior, experienced coordinators able to oversee the system while working on the wards. No longer tied to desks answering phones and chasing bleeps, they are out seeing patients and leading nursing on the wards. 

They also have time to train in advanced skills, such as independent prescribing, physical assessment and history taking, and formulation of immediate treatment plans. 

In the first year since the system was introduced, we halved the number of red and amber incidents – where patients were put at severe or moderate risk of harm – and have not had a single adverse death at night. Doctors can attend to the most urgent needs first, supported by ward nurses who no longer have to wait by the phone. 

Hard data

Now that nurses can stay with patients, there is less risk of falls at night, drug administration and observations can be carried out in a more timely manner, and nurses have more time for direct patient care. 

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

We now know, for example, that technicians rather than doctors are inserting cannulae 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. 

By introducing the new system, we hoped to improve safety in the hospital at night. We have achieved this, and now plan to extend the system for use at weekends and day time. 

This was a clinical transformation, underpinned by information technology. Not only has it improved patient safety, it has made nurses' and doctors’ work easier. 

Now, 11 years on from the start of Hospital at Night, we have found a safer way to care for our patients. There are lessons here for other trusts that agree it is time to modernise Hospital at Night.

 

How the ‘Nervecentre’ Hospital at Night system works 

  • Ward nurses requiring support enter a request into the online software. Hospital at Night coordinators/practitioners receive the request electronically via a PC or handheld mobile device. They then triage for urgency and skill required, and assign the task to the relevant doctor, nurse or technician with a single click. 
  • Coordinators/practitioners can now see in real-time who is on duty, their skill set, where they are, and how busy they are. The best person can be allocated to the task, and if something urgent comes in, the most senior and experienced person can be diverted to deal with it. 
  • Rather than getting bleeps, on call doctors get 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.

Caroline Chapman is consultant nurse for hospital at night at Portsmouth Hospitals NHS Trust 

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