Hospital at Night project Greater Manchester mental health services Bolton, Salford

1
Hospital at Night projectGreater Manchester
mental health servicesBolton, Salford Trafford
Mental Health NHS TrustManchester Mental Health
Social Care TrustPennine Care NHS TrustBrian
JonesProject Manager
2
Hospital at Night model

• Original idea by Dr Elizabeth Paice, Postgraduate
  Dean Director for London,
• Key driver - European Working Time Directive
  (EWTD) - 48-hour working week.
• Best way to achieve effective clinical care at
  night
• One or more multidisciplinary teams
• Full range of skills and competencies
• Meet patients' immediate needs.

3
Hospital at Night ethos

• Competency focus
• H_at_N team composition is centred on its ability to
  deliver a service, appropriate to the potential
  demands placed upon it.
• Move away from having particular grades or tiers
  of doctors and other staff represented in a
  predetermined fashion.
• A MDT multidisciplinary team comprising
  individuals with the core competencies identified
  as having to be available Immediately.
• Allows the MDT multidisciplinary team to call
  on those individuals whose competencies may be
  required at short notice.

4
National Pilots 2002 - 2004

• The Hospital at Night pilot sites gathered a
  significant body of evidence (20,000 clinical
  episodes across 11 trusts) about what happens in
  the hospital during the out-of-hours period.
• This evidence provides strong support for a
  competency-based, multidisciplinary approach to
  staffing the hospital at night. The evidence also
  signals opportunities-
• For non-medical staff to take on a proportion of
  the work traditionally done by doctors at night.
• To move a significant proportion of the work at
  night into the extended day.
• To reduce unnecessary duplication of work
  especially through a reduction in multiple
  clerking.

5
National pilots - findings

• The main conclusions were
• The number of calls in all specialties falls
  markedly after midnight. At 5am, the number of
  calls to doctors is a quarter of the number at
  5pm. However, staffing levels were the same
  throughout the night.
• A very small proportion of out-of-hours work
  relates to patients in a life-threatening
  situation.
• A significant proportion of the night-time work
  is non-urgent and could be brought into the day.
• A reduction in the practice of multiple clerking
  and better administration and other support to
  medical staff at night could reduce medical staff
  workload at night by up to a half.
• g

6

• Data gathered
• 11 sites
• 7 nights (all day at w/e)
• Up to 70 doctors at a time
• Over 20000 clinical episodes

Activity levels fall after midnight but are high
in the evening - Current staffing levels dont
reflect this
7
Activity varies by specialty
8
A significant proportion of the workload could be
redistributed

• Includes
• Requests
• Portering
• Rewriting prescriptions
• Searching and chasing up
• Bleeps needing no action

Minor Procedures
This workload involves unnecessary duplication
9
Minimise doctor input at nightNew roles

• Clinical team leaders
• Nurse practitioners
• Critical care outreach team
• Extended role pharmacists
• Surgical assistants/practitioners
• Anaesthetic assistants/practitioners
• Physicians assistants
• IT Admin Support
• Facilities - a team base - the Control Centre
• Location for Handover
• Food and rest facilities
• The whiteboard
• IT infrastructure

10
Developing and implementing the team
Anaesth
AE
Current Position
Medicine
Surgery
TO
Consultant
SpR
SHO
Nursing
Step 1 - Establish multi-disciplinary team
Multidisciplinary Team Team Leader
Anaesth
AE
Nursing
Medicine
Surgery
TO
Admin
Identify staff competencies training needs
Step 2 - develop competency based team
Gain new competencies
Lose unnecessary medical staff
Competency based team
11
H_at_N Core clinical competenciesAdult Acute
Managing surgical pt. for 30 mins
pre-operative Trauma / ATLS Acute
haemorrhage Recognition of the acute abdomen
Airway assessment management Recognition of the
need for ventilatory support Anaesthesia -
induction/ maintenance Epidural Management of
ITU Transfer of the critically ill Pain
management Care of tracheostomies
Generic Non Clinical Time management Delegation Ri
sk management Leadership
X-ray interpretation Fracture
stabilisation Assessment of vascular
neurological injury Recognition of compartment
syndrome Relocation and fracture reduction
Recognition and management of acute
emergencies Complex medical procedures Pacing Inte
rpretation of investigations
12
H_at_N Core clinical competenciesMental Health ??
Psychiatric History Taking Mental State
Examination Suicide risk assessment
Breakaway De-escalation Child Protection
Legislation Knowledge Application of MHA s.12
MHA Approval
Generic Non Clinical Time management Delegation Ri
sk management Leadership
Administer ECT CPR Manage disturbed
patients Rapid tranquilisation Medical
prescribing Physical examination
13
H_at_N and Greater Manchester mental health services

• We have unique difficulties in implementing H_at_N
  principles
• There are 13 hospitals spread over 500 square
  miles
• Each site usually has one resident doctor out of
  hours
• In some locations the doctor covers emergencies
  in the psychiatric unit, acute unit and AE
• On other sites, they have tertiary care beds
  without emergency admissions
• Interface with adult acute hospitals can it be
  improved?
• Hours monitoring suggests each of the three
  Trusts are within reach of the 48-hour target
• However, resident junior doctors in basic
  specialty training are losing valuable training
  time whilst performing resident night duties.
• Further improvements can be made to
  well-established multi-disciplinary team working
  that lies at the core of the Hospital at Night
  initiatives ethos
• Effective handover
• IT infrastructure
• The H_at_N approach may support a range of service
  modernisations that will assist with the delivery
  of the Mental Health National Services Framework
  (MHNSF)
• Advance Practitioners, Assistant Practitioners
• Non medical prescribing

14
H_at_N for Greater Manchester mental health services

• 12 month project funded by Greater Manchester SHA
• Data collection phased across three Trusts Sept
  Oct for 4 weeks
• Manchester 4th Sept
• Pennine Care 18th Sept
• Bolton Salford Trafford 2nd October
• Detailed analysis of the clinical activity
  baseline at night
• Will be further meetings at each unit to clarify
  the data collection process web based software
  for night staff to input data.
• Your co-operation and support will be crucial

15
(No Transcript)
16
Project Team

• Project Sponsor, Dr Damien Longson
• Project Manager, Brian Jones
• 0161 918 4905
• 07918 630966
• brian.jones_at_pat.nhs.uk
• Project Support, Diana Muramaa
• 0161 921 4902
• diana.muramaa_at_pat.nhs.uk
• Clinical Lead, BST Dr Chris Daly
• Clinical Lead, MMHSC Dr Damien Longson
• Clinical Lead, Pennine Care Dr Vic Harris
• Steering Group with three Trust specific sub
  groups
• Junior doctor representation required at each
  unit

17
H_at_N Resources

• http//www.healthcareworkforce.org.uk/
• http//www.wise.nhs.uk/cmsWISE/WorkforceThemes/In
  to.htm