Northern Ireland

The Western Health and Social Care Trust (Western Trust) in Northern Ireland launched Hospital at Night (HaN) in two of its hospitals in the spring of 2009.

Altnagelvin Hospital in Londonderry is a 560 bed hospital employing over 2,000 healthcare staff, whilst Erne Hospital in Enniskillen, Co Fermanagh is a 200 bed hospital.

HaN is now firmly embedded in the hospitals' out of hours service, operating seven days a week at both; between 7pm and 7am at Altnagelvin, and between 5pm and 1am at Erne.

The main drivers for HaN was the introduction of the European Working Time Directive in all hospitals and the Trust’s aim to improve the working lives of staff, particularly junior doctors, and to improve patient safety and the quality of care at night.

Hospital at Night (HaN) has delivered improved patient safety, a safer medicines policy and a better learning experience for junior doctors in the Western Trust, according to Dr Rose Sharkey, respiratory physician and HaN lead at the Altnagelvin site.

No increase in out of hours clinical incidents has been reported and HaN has also played a key role in moving non urgent work into the daytime.

When an evaluation report was compared to a baseline audit carried out a year before HaN was implemented, it showed that doctors were completing more clinically appropriate procedures with nurses, whilst specially trained healthcare assistants taking responsibility for other tasks.

There is also evidence that risks are being identified earlier, with many of the patients who are transferred to the high dependency unit being admitted with lower early warning system (EWS) scores.

Dr Sharkey believes that team work is at the core of HaN's success with the role of the clinical coordinator, responsible for the effective decision making and for supporting junior medical and nursing staff at its centre.

Healthcare assistants, appointed from a community hospital background, completed an NVQ level 3 in Clinical Healthcare skills, designed for those working in acute hospital settings and covering the skills required by HaN, before joining the team.

This was delivered as an NVQ award which best met the needs and requirements of healthcare assistants in this role.

Dr Sharkey said: "The benefits of Hospital at Night are improvements in patient safety, team work with more continuity of care and the education of junior doctors. All these are benefits which could apply to daytime working if the model was extended to the 24 hour day, which I believe would have a beneficial impact on length of stay."

Nursing practice across wards has been standardised and workbooks, in which staff record all tasks in an organised format, have been introduced. Dr Sharkey said: "This encourages staff to perform tasks, like venepucture, before calling HaN."

The three clinical coordinators at Altnagelvin, all appointed from senior nursing backgrounds, received internal training and studied a two year health assessment module at Queen's University, Belfast. Each has the opportunity to add nurse prescribing to their qualifications.

Their responsibilities include chairing the evening handover with a senior doctor, accepting referrals from nursing and junior medical staff, carrying out clinical risk assessments of patient care depending on need, plus supporting trainee doctors.

Former hospital manager Raymond Jackson, now one of the clinical coordinators, says: "Everyone on duty now works much more as a team. If one doctor has a huge workload and another is less busy, they will share the tasks and pull together.

"Nurses can call the clinical coordinator at any time for advice and we also support our junior doctors when they start at the hospital."

In 2010 two coordinators will be on duty for the month of August; one assigned to medicine, the other surgery to support the new group of junior doctors, compared to only one when HaN was first introduced. Raymond said: "In a 560-bed hospital, it was very difficult for one person to assist the junior doctors but this year they will be even better supported."

At Erne Hospital, Dr Jim Kelly, consultant physician and HaN lead, said: "Hospital at Night means the right patient being seen by the right person at the right time. Our multi disciplinary team consists of doctors, nurses and healthcare assistants who are capable of meeting patients’ immediate needs and who are able to call on specialist expertise when necessary."