Derby Hospitals Split Site Hospital at Night Project

Derby Hospitals NHS Foundation Trust began its Hospital at Night (HaN) project in 2004 with the aims of improving overnight patient safety and compliance with the European Working Time Directive (EWTD) 2009.

Originally a human resources (HR) managed project, HaN at Derby Hospitals was changed into a clinically led project when the need for greater clinical involvement was identified. The trust currently has two main acute sites.

The Derbyshire Royal Infirmary (DRI) site was the first to take up the mantle as it was identified to be the busier of the two at night, with Accident and Emergency located on there.

The project has been embraced by consultants, junior doctors, nurses and staff across the two hospital sites. It has not all been plain sailing, particularly where specialty services are involved. Prior to the EWTD it was difficult to get doctors to respond to audits regarding the work undertaken by trainee doctors at night, but now there is evidence, thanks to the EWTD audits, about what specialty middle grade doctors and others are actually needed for overnight.

Changes to hospital practices have been identified through the HaN project. Dot Ward, HaN project manager said: "Prior to HaN if a nurse had called for someone (a doctor) to attend a patient they may have had to wait quite some time. With the night nurse practitioners (NNPs) the wait is minimal and patients are seen by the most appropriate person in a timely fashion." She went on to say: "We are not trying to turn NNPs into trainee doctors, as some specialty practitioners would argue, but we must develop and retain them and provide them with a career path so that they don’t go elsewhere."

One of the NNPs has undergone a non medical prescribing course and others are set to follow suit.

An early warning system (EWS), used in the critical care team but not previously used in the Medical Directorate, has now been identified as a vital tool in hospital activity. Cath Rowe, nurse consultant in critical care, and her team have undertaken training courses for colleagues across the board made possible through mutual support.

The night now looks very different since HaN became clinically led via the Nursing Directorate.

The project has had the support of a great champion in Medical Director, Dr Kathy McLean. She said: “I am delighted that the HaN project is progressing well. The NNPs have taken to the roles remarkably well and feedback is universally positive. The teams will need to continue developing and will gradually cover more of the hospitals.”

There is now a regular handover, which takes place on the medical admissions unit (MAU) and includes all of the medical night team; two specialty registrars, one F2 and one F1 as well as the sister from the MAU and the NNP. Junior doctors say that they feel more supported at night with HaN in place, thanks to the NNP presence. The NNPs can see patients who in the past would have had to wait for a doctor. This has meant that despite an increase in the number of incidents reported (including those by NNPs), the number of serious incidents has decreased. Patients are now seen in a more timely fashion.

A survey of NNP activities in early 2008 also led to the identification of a need for clinical support workers. These roles are currently being recruited for and will be monitored and reviewed for future development.

There is no doubt that the medical directorate has benefited the most from HaN but there are plans to expand the project into other directorates which were not involved initially due to the perceived difficulties. There are also plans to include a pharmacist and a respiratory physiotherapist in the night team when the two sites become one, in June 2009, if all goes according to plan.

Another potential area for change relates to identity. NNPs currently wear the uniform of clinical nurse specialists but there is a need to provide them with an individual identifier and for the uniform to help them feel part of the night team. The project is continually being audited and updated, a key element of keeping a HaN project alive.