Christchurch Hospital, New Zealand

New Zealand was the first country to introduce working time reform in response to the view that resident medical officer (RMO) employment conditions were debilitating and stressful for doctors in training and potentially dangerous to patients.

When the need for changes in working practices in acute hospitals became apparent (as it did in the UK), a study was completed in 2004 at the 650 bed Christchurch Hospital, a tertiary centre which covers most specialties, to obtain accurate data about medical activity on the 10.30pm to 8:00am night shift.

The results showed that there was an opportunity to match service change with workforce change, requiring a re profiling of staff and an investment in training and education across the clinical professions.

New approaches were required to staff Hospital at Night (HaN), and the out of hours multidisciplinary team was recommended to ensure that sufficient, appropriate staff were available at night with leadership, to protect patients and staff from harm.

Since then, many changes have been introduced at Christchurch Hospital and hospitals across New Zealand are following their example.

Christchurch Hospital is now extending the concept to all of its out of hours services and considering its introduction during the day.

Following HaN, the project team analysed the tasks and services which were completed out of hours to build a picture of the ideal composition and skill mix required for the workforce.

During 2009 they not only looked at the resident medical officers (RMOs) but at the nursing staff (including duty nurse managers and transit care nurses) and technicians, before changing the skill mix for the clinical coordinators and nursing support structure.

Now they are applying the same concept to the daytime where house officer workloads can vary. Yvonne Williams, project facilitator and one of three authors of a report on the 2004 HaN audit in The New Zealand Medical Journal said: "During the day the hospital tends to operate in silos within the specialties.

"The coordinator role has been one of the keys to the success of HaN and we have now introduced that at weekends which were identified as the most risky period after night shifts.

"The coordinators play a huge role in supporting medical and nursing staff, reducing calls to medical staff by 50% and stopping unnecessary paging. They work with and alongside dedicated nursing staff to assess appropriate responses."

The coordinator role has also had a beneficial impact on weekend discharge rate, facilitating the appropriate staff to discharge patients who meet specified criteria and who otherwise would have had to wait until Monday. The role has since been introduced at weekends for medical wards and has been evaluated and audited.

Handovers, first introduced by medical staff from the evening to the night shift, are 'now commonplace and working well', when previously information had only been passed on in silos and there was no overall hospital view.

Although the hospital has not audited the impact of HaN on patient outcomes specifically, they have case studies which show that the coordinator has played a role in early detection of deteriorating patients, avoiding transfer to the intensive care unit (ICU) and so avoiding negative outcomes.

Yvonne admits that at the start, nursing staff felt disempowered by the new system. They challenged the need to go through a coordinator rather than contact a doctor directly, that was until they appreciated that the coordinator was aware of individual doctor workloads and so could direct the calls more appropriately.

Similarly, some senior doctors, mainly consultants, were sceptical of the HaN concept at the start: "Many have now been persuaded and are supportive," she said. "RMOs embraced it and house officers really appreciate it, both say they are now doing the work they are trained to do."

Yvonne said her team has offered advice to many other hospitals and to the district health boards who now want to see the same initiatives rolled out in every hospital in the country: "Our advice to anyone is to make these changes incrementally so that people can see the effect of each change; we suggest starting at night, then weekends, followed by all after hours before looking at daytime."

Executive sponsorship, which Christchurch Hospital gained at the start, is also important, especially when extra resources are required, she said.

For more information: The New Zealand Medical Journal, March 31, 2006 "New Zealand's Christchurch Hospital at Night: an audit of medical activity from 22.30 to 08.00 hours http://www.nzma.org.nz/journal/119-1231/1916/