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Can we make the hospital a safer place at night?

It has been 10 years since the introduction of Hospital at Night. Caroline Chapman, nurse consultant for Hospital at Night, Portsmouth Hospitals NHS Trust, argues it is time to modernise and explains how this can improve safety.

In the dead of night, when the rest of the world sleeps, 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 one of their patients suddenly deteriorates. 

Hospital at Night started in 2005 to address the shortened working week for junior doctors with 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 we ran ours in a conventional way, relying on highly experienced, senior nurses to run a co-ordination centre. Ward nurses telephoned the co-ordinator who would triage the call and bleep the most relevant person. 

It worked reasonably well, but there were gaps. For instance, if I bleeped a doctor, I had no way of knowing if he or she was already busy. The ward nurses were left hanging on the telephone, while the on-call doctors could not tell whether the next bleep was an emergency or a more routine call. We felt there was potential for harm. 

Common themes 

When we looked at our adverse incidents at night we found this impression was true. There were common themes such as errors in communication, patients not being tracked, failure to escalate potentially serious situations and poor record keeping. Senior nurses were largely deskbound to be near a telephone, dealing with hundreds of calls per shift, rather than out and about supporting the wards and giving direct patient care. 

We knew safety was high on the agenda – Don Berwick’s report on patient safety was fresh in our minds – so we set about modernising our Hospital at Night programme to improve safety and quality of care. Using a grant from NHS England’s Nursing Technology Fund, we invested in an electronic task management system with the aim of improving safety. 

It works like this. Ward nurses requiring support enter a request onto the online software. Hospital at Night co-ordinators/practitioners receive the request electronically via a PC or tablet, triage for urgency and skill required and assign the task to the relevant on call doctor, nurse or technician with a single click. 

As a co-ordinator/practitioner, I can now see in real time who is on duty, their skillset, where they are, and how busy they are. Our on call doctors no longer get bleeps but an alert on their mobile device with details of the task. 

A safer system 

Implementing our new system involved significant change to our processes, but even so we found staff adapted quickly and easily. Our new Nervecentre Hospital at Night system is very pro-nursing. Our co-ordinators, who are very senior and experienced staff, are no longer tied to a desk answering the phone and chasing bleeps. They are now able to oversee the system while working on the wards. 

In the first year we halved the number of red and amber incidents, in which patients were put at severe or moderate risk of harm, and we haven’t had a single adverse death at night. 

Hard data 

With a proper audit trail, we now know what our on call clinicians are doing at night, and we can review incidents in much more detail. We now know, for example, that technicians and not our on call doctors are inserting cannulas 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. 

We hoped we would improve safety in the hospital at night and we have achieved this. Now we are keen to make more use of the electronic task management system by extending it to the weekend day time. A decade on from the start of Hospital at Night, we have found a safer way to care for our patients. We think there are lessons in our experience for other trusts that agree it’s time to modernise hospitals at night.

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