Table 1 Comparison of changes at Guy’s and St Thomas’ NHS Foundation Trust versus Homerton University Hospital NHS Foundation Trust
From: Hospital at night: an organizational design that provides safer care at night
Guy’s and St Thomas’ NHS Foundation Trust | Homerton University Hospital NHS Foundation Trust | |
Key drivers | Patient safety Regulatory requirement to reduce doctors’ hours Controlling costs Maintaining/improving medical training | Patient safety Regulatory requirement to reduce doctors’ hours Maintaining/improving medical training |
Key outcomes | Reduction in HSMR Reduction in serious incidents Reduction in health care–associated infections 100% compliance with EWTR Maximum cost of £2.4 million | Reduction in HSMR No increase in serious incidents Reduction in health care–associated infections 100% compliance with EWTR |
Data collection | Analysis of on-call duties Analysis of rotas Creation of competency matrix | Presentations and discussions on how to improve patient care |
Hospital at Night | SNPs with both clinical and site management responsibilities Structured handover at the same time for all specialties Baton bleeper for face-to-face handovers First point of contact for wards and other areas Twilight shifts for specialties (majority removed for overnight) On-call teams covering patients from all specialties Consultant ward rounds by Surgery and General Internal Medicine every 12 hours for all admissions SNPs see, assess, treat, and /or refer acutely ill patients 18 pathways (with associated protocols) for common emergencies | Clinical Site Manager Team with both clinical and site management responsibilities First point of contact for wards and other areas Single team for emergency admissions via emergency department Single team to cover inpatients |
Taking Care 24/7 | Extension of H@N into the day Physician of the week for surgical inpatients working with surgical teams Single escalation system for both sites Single admissions area for elective surgical patients Handovers for planned discharge and weekend care Regular contact with wards and doctors by SNP every 6 hours 24/7 | Separation of elective and emergency work Single admissions area for elective work Acute Care Unit Doctors work only in one or the other pathway for set periods of time, thereby maximizing training opportunities Consultant in General Internal Medicine present in emergency area 12 hours per day Factual handover at 8 a.m. Elective to emergency team handover at 4 p.m. |
Impact on patient care | Initial reduction in HSMR Sustained reduction in serious incidents Reduction in health care–associated infections Reduction in in-hospital cardiac arrests Reduction in lengths of stay | Initial reduction in HSMR Reduction in health care–associated infections |
Financial impact | H@N: £4.1 million saving; £2.4 million in recurrent costs 24/7: closure of 250 beds | H@N: £100,000 saving 24/7: £600,000 saving; £250,000 in recurrent costs |
Educational impact | H@N: no change in feedback from junior doctors 24/7: improved teaching time participation for most junior staff and physicians (daily seminar from physician of the week) | H@N: no change in feedback from junior doctors Sustained hours of direct supervision/elective work Reduction in hours spent in “acute care team” for each doctor Educational handover at 10 a.m. |
Lessons learned | Need involvement of all staff, not just medical Need good, relevant data Training for staff who are extending/changing their role The change is part of a whole system change that continues to evolve; 24/7 is only one part that contributes to the improvement as a whole | Need involvement of all staff, not just medical Need good, relevant data Training for staff who are extending/changing their role The change is part of a whole system change that continues to evolve; 24/7 is only one part that contributes to the improvement as a whole |
Sustainability | Yes – no appetite to return to the on-call system | Yes – no appetite to return to the on-call system |