Stories about the inefficiencies of out of hours care abound but there is little data to pinpoint the problem areas. Dominick Shaw, John Blakey and Gemma Housley outline a project that highlights these so solutions can be found

Doctor with a clock

Are crucial decisions on long-term management by senior clinicians really required at night?

Clock doctor

The debate continues in the media about the need for 24/7 working in secondary care. “Why can’t the health service be more like a 24/7 supermarket?” ask its critics. “Consultants need to do more!” opine the papers. But more of what?

‘As a consequence of the Hospital at Night programme, fewer doctors are available on the wards at any one time, despite an annual 15 per cent increase in admissions’

Are crucial decisions on long term management by senior clinicians really required at night? What actually is required 24 hours a day? The key to a rational debate about resource allocation depends on understanding what work is generated out of hours. This article attempts to delineate the type of work required for patient care all day, seven days a week.

Current out of hours staffing

In most NHS institutions, out of hours care covers the period of clinical activity on weekdays from 5pm-9am, and all day at weekends and public holidays. This actually accounts for 75 per cent of the entire working year. To meet out of hours clinical demands most hospitals still use the Hospital at Night programme, introduced in 2006 to comply with the European Working Time Directive.

As a consequence, fewer doctors are available on the wards at any one time, despite an annual 15 per cent increase in admissions. This out of hours reduction in staff numbers also applies to allied healthcare professionals (physiotherapists, pharmacists, radiographers, phlebotomists and so on) and ancillary support staff (such as porters, information and communication technology staff and cleaners).

The reduction in medical staffing has been suggested as a cause for the observed increase in mortality at weekends. However, employing more staff to augment out of hours provision is unlikely to happen for obvious financial reasons.

How are staffing levels decided?

In most institutions the Hospital at Night team carries out the majority of the work required during the out of hours period. More senior doctors are either present on site or are on call from home and drafted in as the workload mounts.

Trusts can employ doctors in non-training posts but, for a variety of reasons, these posts are very difficult to fill. Similarly, senior doctors are often used to cope with the volume of work at night, not necessarily with more complex cases. Indeed, most organisations have been complicit in this arrangement despite the available data − as an example, the number of junior doctors present in out of hours is usually fixed throughout the year, despite the marked seasonal variation in workload.

Capturing workload

The number of hospital admissions is easily measured and often used as a proxy for total workload, but patients already admitted to hospital who require ongoing care generate a large proportion of work that occurs out of hours. Capturing the work and care requirements generated by this fluctuating bed base is challenging. 

‘We can now review requests from wards or departments with apparently high levels of daytime overspill and assess how this might be improved’

The deployment of a wireless task flow solution, called Nervecentre, in Nottingham has not only improved our out of hours communication and staff satisfaction but has crucially also allowed us to measure how much work is undertaken, of what type, by whom, where and when.

In this system a ward based nurse enters a task, such as a request to prescribe intravenous fluids, through an interface on the ward computer. The standard format of the request interface ensures a consistent and accurate set of information is captured for every request. Once submitted, the request is sent to a coordinator carrying a mobile device.

Based on the priority, location and details of the request, and live data on the current activity of junior doctors, the coordinator then allocates it to one of the Hospital at Night team. Once the coordinator selects a recipient (a doctor or support worker) the information is sent directly to their smartphone for them to indicate their acceptance and, later, completion of the task.

Tasks are categorised as red (urgent), amber (soon) and green (non-urgent) based on predefined criteria. We therefore have a live summary of the activity of the Hospital at Night team and a permanent record of work at the level of individual staff, patients, wards or departments. This gives us an overview of what exactly is required of out of hours care and of who is doing what.

Leveraging the data

Before Nervecentre’s implementation, time pressures and the outdated pager system limited centralised record keeping; detailed information was only collected if a significant incident occurred. The data now collected is much more revealing and helps shape our practice.

‘Junior doctors take longer to perform a task; this is unsurprising but we now know exactly how much longer these tasks take and what we might reasonably expect them to do in a shift’

In Nottingham City Hospital and Queens Medical Centre, for adult medicine and surgery, 152,544 tasks were requested of the Hospital at Night team in 2012. Of these, 6 per cent were red calls, 30 per cent amber and 64 per cent green. The total number of tasks requested over the year varied widely by specialty. The number of urgent calls ranged from 23 per bed per year in haematology to one for spinal surgery.

Data such as this stops senior doctors competing for more out of hours juniors for their wards, and staff are deployed where the work actually occurs. These data can also be used to direct improvements in daytime care. This is reflected in the spike of green tasks that occurs between 5pm and 7pm. We can now review requests from wards or departments with apparently high levels of daytime overspill and assess how this might be improved though education or additional support.

Of the 150,000 requested tasks, 37 per cent were undertaken by a foundation year doctor, 24 per cent by a specialist trainee doctor, 19 per cent by a clinical support worker, 9 per cent by a locum doctor, 6 per cent by a coordinator and 3 per cent by a medical or surgical registrar.

Junior doctors take longer to perform a task; this is unsurprising but we now know exactly how much longer these tasks take them and, therefore, what we might reasonably expect them to do in a shift.

Understanding the obvious

Although the most obvious use of the data is for staff rostering with shift times matching demand, we are beginning to explore other uses for the data.

‘In the absence of data, workforce planning will remain under the influence of political ideology and public opinio’

Medical students feel unprepared for on-call shifts and see task prioritisation as a major cause for concern. Using the data captured we have produced a computer simulation using video game sensibilities that foundation year 1 doctors use prior to starting work. The simulator is geographically accurate and tasks appear with the same frequency and location as on a real shift; these are allocated and prioritised by junior doctors in line with the trust’s policies and guidelines.

We are also using novel and highly accurate indoor positioning technologies to capture data about staff movements around the wards and hospitals. This is linked to the task capture data with a view to designing a more efficient ward and hospital layout.

An obvious initial finding has been that all wards have different layouts for equipment, forms and note trolleys. We can now measure the time spent searching for a cannula or drug card and calculate the time saved by standard ward and equipment layouts.

We have demonstrated that introducing newer technologies is acceptable to frontline staff, reduces costs and clinical risk, and can provide true insight into staffing needs in secondary care.

In the absence of data, workforce planning will remain under the influence of political ideology and public opinion, distorted by the lens of the popular press. It is time for us to provide an evidence based service to deliver evidence based medicine; anecdotes do not data make.

Dr Dominick Shaw is associate clinical professor at Nottingham Respiratory Research Unit and clinical lead for Hospital at Night, City Hospital Campus of Nottingham University Hospitals Trust dominic.shaw@nottingham.ac.uk; John Blakey is senior lecturer, clinical sciences at Liverpool School of Tropical Medicine, John.Blakey@liverpool.ac.uk; and Gemma Housley is information analyst for Hospital at Night, Information Services at Nottingham University Hospitals Trust, Gemma.Housley@nuh.nhs.uk

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