Hospital at night: an organizational design that provides safer care at night

Background Delay or failure to view test results in a hospital setting can lead to delayed diagnosis, risk of patient harm, and represents inefficiency. Factors influencing this were investigated to identify how timeliness and completeness of test review could be improved through an evidence-based redesign of the use of clinical test review software. Methods A cross-section of all abnormal hematology and biochemistry results which were published on a digital test review platform over a 3-year period were investigated. The time it took for clinicians to view these results, and the results that were not viewed within 30 days, were analyzed relative to time of the week, the detailed type of test, and an indicator of patient record data quality. Results The majority of results were viewed within 90 min, and 93.9% of these results viewed on the digital platform within 30 days. There was significant variation in results review throughout the week, shown to be due to an interplay between technical and clinical workflow factors. Routine results were less likely to be reviewed, as were those with patient record data quality issues. Conclusion The evidence suggests that test result review would be improved by stream-lining access to the result platform, differentiating between urgent and routine results, improving handover of responsibility for result review, and improving search for temporary patient records. Altering the timing of phlebotomy rounds and a review of the appropriateness of routine test requests at the weekend may also improve result review rates.

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“…To some degree the effect of shift handover may be explained by a transition from urgent to routine care, as previously described. 28 …”

Section: Resultsmentioning

confidence: 99%

Factors influencing digital review of pathology test results in an inpatient setting: a cross-sectional study

et al. 2020

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“…These configurations also acknowledged the need for a specific focus on after hours care and a focus on improvements in communication and interactions between teams. [14][15][16][17] Using concepts of these prior models, the SAFE model was developed to attempt to incorporate the features of successful daytime clinical teams into out of hours working, while valuing and strengthening the role of the senior nurses who had traditionally contributed to organisational resilience. The model developed allowed strong internal leadership with clear external accountability and governance, while encouraging good professional habits of communication, proactive care and appropriate delegation and escalation.…”

Section: Methods 21 Model Designmentioning

confidence: 99%

The ‘SAFE’ initiative – An innovative approach to safer patient care in a tertiary hospital setting

Krishnasivam

Bennett²,

Birkett³

et al. 2019

JHA

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Introduction: Out of hours inpatient care within Australia, defined as the hours outside of 0800 to 1600 hours Monday to Friday, is traditionally provided by on-call medical teams, working in silos, supported by onsite junior medical staff. This model can be associated with poor communication both between and within teams, lack of accountability, failure of escalation, and a reactive model of care. International literature reveals that the outcomes of patients admitted to hospital out of hours are poorer, resulting in a discrepancy in mortality between in and out of hours admissions.Methods: We aimed to reduce the discrepancy in mortality between in and out of hours admissions, as well as reducing overall inpatient mortality. Using a resilience engineering approach, we introduced a novel model of out of hours care - the ‘Safety After Hours for Everyone’ (SAFE) Team. This incorporated a departmental model, with clear and robust internal leadership, external accountability, and formal processes for identification, review and follow up of at risk patients, as well as protocolised escalation processes.Results: The introduction of the SAFE model has been associated with a continuous reduction in the overall Hospital Standardised Mortality Ratio (HSMR) from 0.71 to 0.54 (periods January to March 2015 vs January to March 2018. In addition, the SAFE model has been associated with a reduction in out of hours mortality (defined as admissions from 1600 to 0800) from 0.98 to 0.38 (periods January to March 2015 vs January to March 2018). This has been accompanied by a qualitative improvement in the quality of care delivered out of hours, and improved satisfaction with working conditions and training delivered out of hours. Due to a drastic reduction in unplanned Resident Medical Officer (RMO) overtime associated with the introduction of the model, implementation was near cost neutral.Conclusion: The introduction of the SAFE model has been associated with improved hospital outcomes, in conjunction with improved medical and nursing staff experiences, at a low marginal cost. This model has scope to be applied to similar tertiary level hospitals, or modified to fit within most hospital structures. A key component to the success of this model’s innovation, is acknowledgement of the importance of after hours care provision to patients, highlighted by the formation of a department of after hours medicine as part of the SAFE model.

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“…By 2008, majority of the hospitals in England had an H@N service. 2 Apart from medical doctors, other key members of an H@N are critical care outreach teams (CCOTs), the resuscitation team and site practitioners. CCOTs are generally experienced nursing staff with prior experience of intensive care.…”

Section: Outline Of Problemmentioning

confidence: 99%

Quality improvement report: setting up a hospital at night service, limitations of bleep filtering and using an electronic task management system

et al. 2021

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The ‘hospital at night’ concept was developed at a joint conference of the London Deanery and Clinical Staff in 2002, as an issue for education and service provision. At the start of the project, our trust had issues with both the structure of the hospital at night handover and the working practices overnight. The vision was to improve team working out of hours, expedite review of sick patients and reorganise care to seek a reduction in bleeps to medical junior doctors overnight in a way that all patients had access to the right person with the right skills for their needs at the right time. The hospital at night project at our hospital was started in 2019 by a multidisciplinary working group. We tried bleep filtering for 4 months and this was later followed on by the development of an electronic out of hour’s task list as part of our hospital at night set-up. The bleep analysis data showed an improved distribution of workload but the process was dependent on individuals. The electronic task management system was built in pre-existing online software. The system helped prioritise and review tasks requested by nurses on medical wards. But it was not without its limitations. We worked with the local information technology (IT) team to improve speed and proposed developing an IT solution that is fast and not desktop based to ensure tasks can be assigned and viewed while on the go. The project was overall a success as it demonstrated positive feedback from junior doctors, improved perception of teamwork and ability to take rest breaks. It also demonstrated a drop in ward-based cardiac arrest rates. The hospital at night project at our trust remains a work in progress, but a lot of positive changes have been delivered.

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Hospital at night: an organizational design that provides safer care at night

Cited by 20 publications

References 9 publications

Factors influencing digital review of pathology test results in an inpatient setting: a cross-sectional study

Factors influencing digital review of pathology test results in an inpatient setting: a cross-sectional study

The ‘SAFE’ initiative – An innovative approach to safer patient care in a tertiary hospital setting

Quality improvement report: setting up a hospital at night service, limitations of bleep filtering and using an electronic task management system

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