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www.londondeanery.ac.uk
Duty Hours: Solutions across borders
For better, safer patient care and more effective learning
September 2011
Dr Fiona Moss Director of Medical and Dental Education London Deanery
What we know:
• Sleep deprivation is bad for health
• Sleeping at night is best for health
• Working at night is not good for health
• Some patterns of night working are less harmful than others
• Errors are more frequent when tasks are done at night
• Sleep deprivation stops learning
UK trainee survey:
• 9% made a serious or potentially serious error • Associated with sleep deprivation
• Associated with long hours
UK trainee survey: doctors working long hours
More likely to: • feel bullied • feel ill with stress
Less likely to: • receive informal feed back from consultant • describe consultant supervision as excellent
• describe practical experience as good to excellent • recommend their post to a friend
Overall Satisfaction with Training Post
Practical experience 0.781**
Supervision
0.654**
Department teaching
0.404**
Induction 0.412**
Informal feedback 0.368**
Working beyond hours -0.219**
Sleep-deprived at work -0.293**
Spearman’s rho corr. coefficient
**Correlation is significant at the 0.001 level
What we know:
• Some hospital patients need expert medical care during night hours
• Night care should be delivered by competent experts
020406080
100120140160180200
7-8pm
8-9pm
9-10p
m
10-11
pm
11-12
am
midnight-1
1am-2a
m2-3
am3-4
am4-5
am5-6
am6-7
am7-8
am
Num
ber
Cal
ls
Clerking
Review
Op/Anaesth
Med Proc.
Minor Proc
Advice
Admin/Presc
All types of activity fall after midnight
(from DH pilot)
0
50
100
150
200
250
Unwell
Normal
Life or Limb
Few calls are for patients with life threatening problems:
(from DH pilot)
What we also know:
• Functioning teams are good for health care outcomes
• Poorly functioning teams are not
Teams save lives
92949698
100102104106108
<40% 40-59% 60-79% 80-99% 100%
Mea
n m
orta
lity
inde
x
%staff working in teams
Source:
Health Care Team Effectiveness Project, Aston University
The questions are :
• How do we best provide the expert care that some hospital patients need during the night hours?
• How best do we train doctors in acute care of patients?
Why are we where we are?
• Decades of concern and stories in general press about the impact of tired, overworked doctors on their patients and themselves
• New Deal and European legislation (EWTR)
• Legends of heroes and badges of honour
• Huge advances in medical technology
• A serious lack of leadership and organisational skills training in yesterday’s medical education
• Many of today’s “leaders” not appropriately skilled
Medicine used to be
simple, ineffective and
relatively safe. Now it
is complex, effective
and potentially
dangerous.
Advances in medical technology
• Myocardial infarction
• Chronic Heart Failure
• Diabetes
• Renal failure
• Laparoscopic surgery
• Interventional radiology
• Stroke care
Changes in the organisation of care
• More ambulatory specialist interventions
• Pathways of care
• Chronic disease
• Massive changes in information technology
• Increased patient expectations
• Fewer more specialised centres
• More care in primary care setting
Hyper acute stroke units in London
Shorter hours: we are behind the curve
• Just one of many changes
• Huge changes in many other aspects of care
• Previous approaches to organising acute medical care
– worked well at another time
• Previous approaches to organising medical training “OK” for 20th Century technologies and challenges
• Acute care and training in acute care both need a complete review
Every system is perfectly designed to produce precisely the results it delivers. Paul Bataldan, Don Berwick, Institute for Health Improvement 1997
Whole System Approach
Workload at night
Reduce out of hours operating
Treat & Transfer Maximise
primary care contribution
Draw work into Extended Day
Simon Eccles
Moving work away from night
• Increase staffing and activity during the day and evening
• Specialist teams available to sort problems until late evening
• Clear all the day’s work by midnight
• Ensure ready access to walk-in emergency clinics, senior review, operating theatres etc first thing in am
The Night Team
• A single multi-professional team with the skill set to cover hospital at night
• Clinical site practitioners
• Leader who organises and directs activities
• Team members to encompass a range of specified skills
• Supported by specialists on call from home
• Requires organisational and behavourial changes
The Night Team Remit
• Wards and A&E
• Emergencies only
• Defer where possible to morning
• Protocol driven • Clear lines of accountability
• Access to specialists when needed
• Consultant led handover morning and night
Guy’s hospital: night teams results • Reduced patient risk
• Better handover and improved communication
• Reduction in clinical incidents
• Reduction in mortality rate
• Improved team-working out of hours
• Improved training & support for junior staff
• Recurrent saving £4.1million
Guy’s & St Thomas’s 2003-2008
H@N introduced
H@D&N introduced
Quote from Temple Report
Homerton University Hospital NHS Foundation Trust: ‘Hot’and ‘cold’ realignment of services Teams work in parallel to meet the service needs. The
consultants have extended their working day to. In each six-month timeframe trainees spend six-week periods on emergency ‘hot’ work and then the remainder of time on ‘cold’ elective employment. When they are on the ‘hot’ team they work mainly in ACU and A&E, they have strong consultant leadership and they work as part of a well-defined multidisciplinary team. When they are on the ‘cold’ team they are ward based, their work has a strong multidisciplinary focus, they work mainly 8am to 5pm or 9am to 6pm and, importantly, they have protected teaching time enabling them to maintain continuity of patient care and see the patient journey.
Homerton Hospital
• Elective emergency split (service and training)
• Recognise most emergencies are “medical”
• Even in “non-medical” patients
• Avoiding increases in doctor numbers for all tiers of all rotas
• Minimise night and weekend working • Expand ‘normal’ working day
Homerton University Hospital, Dr Foster 2010
Impact on Faculty:
• Increased the amount of day time training • As when work with electives mostly worked weekday hours • Attend procedures, operations, clinics etc with own consultants
• Have lost ‘I am Dr X’s registrar’
• Now “Cardiology service registrar”
• Consultants do say ‘I never see my reg’
• Stuck in traditional paradigms of service and training
• Still have to crack some cultural issues
• Saved £250,000/annum
Great Ormond Street
• Robust team for 24/7 cover
• PEWS and SBAR and handover all identify the sick • Clinical Site Practitioners – day and night CSPs
• Residents: on nights one week in twelve
• Complain about “tasks” left over from the day
• Main challenge: ensure night doctors work as a team
• Most residents 80+ around during the day
• Maximum learning opportunities: attend “own” clinics,
operating lists etc
Impact on Faculty
• More unsocial hours and “coal face” work.
• More responsibility for patients and for supervision
• Less able to depend on “my” trainee knowing “my” patient.
• Few seminars with sleeping residents
• Fewer home calls at night
• More satisfaction as patient outcomes improve • More chance of engaging residents in service reform
Important to beware of:
“Paradox of reform without change”
London: Hospital at Night “Dashboard”
• Multidisciplinary working
• Multidisciplinary hand over
• Clear leadership of H@N team
• Clear roles and responsibilities
• Bleep filtering
• Hospital H@N protocols and policies
• Accountability to Hospital Board • Educational value to H@N team
