Hospital at Night: The Royal Infirmary of Edinburgh

The Royal Infirmary of Edinburgh is an 870 bed tertiary referral teaching hospital which, until the implementation of Hospital at Night (HaN) in 2006, operated a mixture of on site shift based cover and traditional on call cover.

In a study thought to be the first of its kind, detailed information was collected for 14 consecutive nights before the introduction of HaN and 14 nights after. This was taken from the combined surgical and medical assessment unit (CAU), the 18 medical/surgical wards (the ward arc) and the four high dependency units (the critical care corridor).

Following an overnight episode of clinical concern, data was gathered on response time, seniority of staff, patient outcome and the use of standardised early warning score (SEWS).

In total 425 episodes of clinical concern were recorded in 407 patients.

Every ward was telephoned at the start of each night shift to ensure staff were aware of the study, carried out first in September 2006 and after HaN implementation in October 2007. Completed date forms were collected each morning before the night shift ended.

The authors of the study report, then both based at the royal infirmary, were doctors Daniel Beckett, now consultant in acute medicine at Stirling Royal Infirmary, and Claire Gordon, now consultant in acute medicine at the Western General Hospital, Edinburgh.

Significant improvements in both patient and systems outcomes were found in the 14-day 'before and after’ study of HaN with no adverse effects noted.

Now the results are being used to decide whether to extend HaN to the daytime and to instigate improved teamwork.

Three important benefits were identified. Patients in the CAU and critical care corridor were more likely to be reviewed by senior medical staff, the incidence of adverse outcomes in the CAU and ward arc reduced significantly, plus response times across the wards (where previously discrepancies had existed) were standardised.

Dr Daniel Beckett said: "It is important that all three are linked. The second study showed a standard response time across the wards, where before there had been real discrepancies between ward areas and the level of seniority of the doctor who would attend them.

"Because patients on some wards were seen by more senior doctors as there was a registrar on site overnight, there was a reduction in the number of adverse outcomes."

Defined as cardiac arrest or unplanned transfer to critical care, overnight adverse outcomes reduced from 17% to 6%, and the incidence of cardiac arrest from dropped from 4% per cent to 0%.The number of incidents which were not reviewed before the end of the night shift fell from 2.5% to1.4%.

Dr Claire Gordon says: "All these benefits are partly as a result of managing and sharing the workload more sensibly with the result that fewer jobs are likely to be left until the morning.

"HaN could divert anyone to any ward to see any patient and there was a better division off labour. It is all about using the right person at the right time in the right place."

She said that the medical handover introduced with HaN was safer: "It happens in 'bleep free' time and is written down, and we are learning from it in other areas where a medical handover is used."

Both doctors admit that the introduction of HaN was controversial and experienced 'some teething troubles' at the start, leading to the accepted need for protocols for certain aspects of care.

"Now, the doctors working in the team feel HaN works well and is supported. There are many good examples of how the workload can be managed by multi disciplinary teams which are well organised."

Their advice is to ensure stakeholders are in support of HaN and to adopt 'a whole systems approach with appropriate buy in' to ensure success.

Daniel is part of a group whose bid to evaluate the impact of HaN on patient safety, hospital efficiency and staffing, performance and economic outcomes has been shortlisted for national research funding. It has already passed the scrutiny phases of the National Institute for Health Research, Service Delivery and Organisation Programme.

The report Improvements in out-of-hours outcomes following the implementation of HaN" QJ Med 2009; 102:539-546 21 May 2009.