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

Abstract

The reduction in the working hours of doctors represents a challenge to the delivery of medical care to acutely sick patients 24 hours a day. Increasing the number of doctors to support multiple specialty rosters is not the solution for economic or organizational reasons. This paper outlines an alternative, economically viable multidisciplinary solution that has been shown to improve patient outcomes and provides organizational consistency. The change requires strong clinical leadership, with organizational commitment to both cultural and structural change. Careful attention to ensuring the teams possess the appropriate competencies, implementing a reliable process to identify the sickest patients and escalate their care, and structuring rotas efficiently are essential features of success.

Figure 1

Average number of calls received per overnight shift. Data source: UK National Audit 2003.

Figure 2

Escalation of care for sick patients at Guy’s and St. Thomas’ NHS Foundation Trust. SNP = senior nurse practitioner; PAR = patient at risk.

Figure 3

Average total calls received per day at Guy’s Hospital, London, UK, after the implementation of Taking Care 24/7, 2008–2009. Data source: Senior Nurse Practitioners, Guy’s and St Thomas’ Foundation Trust.

Figure 4

Quarterly in-hospital relative risk of mortality, with 95% confidence intervals, for all non-elective admissions, Homerton University Hospital, London, UK. Values shown in green are statistically significant deviations from expected values.