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  • 1. Assessment of clinicalAssessment of clinical risk and outcomerisk and outcome measures in the out ofmeasures in the out of hours hospitalhours hospital Claire Gordon Specialist Registrar Intensive Care Medicine Daniel Beckett Specialist Registrar Acute Medicine Royal Infirmary of Edinburgh, UK
  • 2. Introduction • There is evidence that for the acutely unwell, care overnight is often sub-optimal • The Hospital at Night project is being widely introduced across the United Kingdom as a mechanism to maintain quality out of hours healthcare in the face of the European Working Time Directive
  • 3. Introduction • Our study aimed to – quantify the numbers of patients at risk overnight, – evaluate the use of a validated SEWS system – assess clinical outcome prior to the introduction of a hospital at night policy
  • 4. Background • The Night Time Acute Cover Working Group of the Royal College of Physicians of London (2002)1 highlighted deficiencies in quality of healthcare overnight – Half of all units reduced doctors on call overnight – Suggested that reduced level of medical staffing correlates with mortality2
  • 5. Background – Doctors covering on average 67 patients per night, others more than 200 – In one third of units there were no first year doctors involved in overnight care, which is a significant training issue – In 30% of units there was no resident registrar overnight, resulting in no senior supervision of patient care
  • 6. Background • NCEPOD ‘Who Operates When? I’ report in 1997 highlighted that operations overnight (0000 – 0759) were carried out by less experienced surgeons, with less experienced anaesthetic support3 • Significant improvements made by 2003 (‘Who Operates When? II’) but there remains a significant disparity between seniority of staff during the day and at night3
  • 7. Background • There is evidence of an increase in early mortality (within 48 hours of hospital admission) of patients admitted at night4 • The overall relative risk of mortality as an in-patient is increased for those admitted at night5 • Night time discharge from ITU to the ward is associated with increased mortality6,7
  • 8. Background • Traditionally overnight NHS hospitals have relied on speciality specific tiers of doctors with the most junior staff resident and consultants on-call from home • Concerns regarding excessive hours, poor performance and detriment to patient care
  • 9. Background • More recently the European Working Time Directive (EWTD) has acted as a major catalyst for changing the working pattern of doctors in training – Stipulates a maximum 56 hour working week by August 2007 – 48 hour week by August 2009
  • 10. Background • Hospital at night piloted in 2003 in UK – ‘Redefine how medical cover is provided in hospitals during the out of hours period’ • Multidisciplinary night team • Cover is defined by competency rather than professional demarcation
  • 11. Background • Key elements of Hospital at Night – Supervised multi-speciality handover – Extended roles of nursing staff including limited prescribing – Bleep filtering through central coordination – Moving a significant proportion of non- urgent work from the night into the evening or daytime – Reducing unnecessary duplication of work
  • 12. The Study • The Royal Infirmary of Edinburgh, an 870 bedded teaching hospital • Hospital at Night was implemented in October 2006 – integral part of the redesign of NHS Lothian acute care services • H@N prospectively to cover all 18 level 1 wards plus 4 high dependency areas
  • 13. The Study • Prior to the implementation of Hospital at Night, the hospital adhered to a traditional on-call policy – First year doctors on site overnight (6 PRHOs, 2 SHOs as first point of contact) – Uneven distribution of workload (eg orthopaedic house officer covering 4 wards, vascular house officer just 1) – Registrars and consultants on call from home – SHOs available but may be in theatre or A&E
  • 14. The Study • Our study aimed to quantify the numbers of patients at risk overnight, evaluate the use of a validated SEWS system and assess clinical outcome • To enable accurate matching of capacity and demand
  • 15. Early Warning Scores • Patients have documented clinical deterioration (or new complaints) in the hours leading up to cardiopulmonary arrest – 84% of patients in the preceding 8 hours8 • A failure of systems to recognise and effectively intervene
  • 16. Early Warning Scores • First developed in 1997, points are allocated according to derangement of physiological parameters9 • Elevated modified Early Warning Score (MEWS) on admission to medical unit associated with increased risk of death, or need for critical care10
  • 17. Early Warning Scores • Use of MEWS encouraged by The Royal College of Physicians report ‘The Interface between Acute General Medicine and Critical Care’ in 200211 • NCEPOD report ‘An Acute Problem’ in 2005 highlighted that 27% of hospitals still did not use an early warning system12
  • 18. SEWS • Scottish Early Warning Score – Heart rate – Blood pressure (systolic) – Oxygen saturation via pulse oximetry – Respiratory rate – Temperature – (GCS/Urine output) • Score of ≥4 necessitates medical review within 20 minutes
  • 19. SEWS
  • 20. SEWS • Admission SEWS correlates with in hospital mortality and length of stay • Following the introduction of the scoring system in the Royal Infirmary of Edinburgh, in-patient mortality decreased13
  • 21. The Study • Observational study • 17 nights (2000-0800) • All 18 level 1 wards plus the Combined Assessment Area (CAU) – Critical care subject to separate evaluation
  • 22. The Study • Incidents of clinical concern or patients triggering SEWS ≥4 • Response times • Seniority of doctor attending patient • Initial Scottish Early Warning Score (SEWS) • Change in SEWS as a surrogate marker for clinical status • Incident outcome by 0800
  • 23. Results • 136 incidents of clinical concern were recorded – 80% within the ward arc – 20% within the Combined Assessment Area • SEWS recording better undertaken in the Combined Assessment Area – 92% had the 5 main physiological variables recorded, compared with 50% on the ward arc
  • 24. Results • 56/136 patients scored SEWS ≥4 – Median response time 5 minutes (mean 23 minutes, range 0 – 280 minutes) – 82% seen within protocol prescribed 20 minutes
  • 25. Results Speciality Median response time CAU 5 minutes General surgery 5 minutes Vascular surgery 2 minutes Orthopaedics 5 minutes General medicine 5 minutes Cardiology/Respiratory 3.5 minutes Renal 7.5 minutes Elderly medicine/GI 5 minutes
  • 26. Results • No significant difference between surgical wards, medical wards and CAU with respect to response times to patients with SEWS ≥4
  • 27. Results 1 hour 4 hours 0800 Improved 69% 86% 80% Stable 26% 11% 15% Deteriorate d 5% 3% 4% • SEWS ≥4
  • 28. Results • SEWS ≥4 • Outcome at 0800 – 44/56 (79%) stabilised on the ward – 7/56 (13%) transferred to critical care – 5/56 (9%) deaths •3 cardiac arrests •2 patients not for escalation of treatment
  • 29. Results • 80/136 patients scored SEWS <4 but caused clinical concern – Median response time 10 minutes (mean 25 minutes, range 0 – 330 minutes)
  • 30. Results Speciality Median response time CAU 5 minutes General surgery 10 minutes Vascular surgery 15 minutes Orthopaedics 50 minutes General medicine 1 minute Cardiology/Respiratory 12.5 minutes Renal 17.5 minutes Elderly medicine/GI 5 minutes
  • 31. Results • Response times in CAU quickest in the hospital. Significantly better than – orthopaedic (p<0.001) – vascular (p<0.001) – general surgery (p=0.04)
  • 32. Results • Response times in orthopaedic wards significantly slower than – general medicine (p=0.003) – elderly medicine/GI (p=0.01) – cardiology/respiratory (p=0.03) – general surgery (p=0.003) • Response times in vascular slower than – elderly medicine/GI (p=0.004) – general medicine (p=0.006) – general surgery (p=0.004)
  • 33. Results • SEWS <4 • Outcome at 0800 – 69/80 (86%) stabilised on the ward – 9/80 (11%) transferred to critical care – 2/80 (3%) deaths •2 cardiac arrests
  • 34. Results • Seniority of attending doctor SEWS ≥4 SEWS <4 FY1 51% 58% FY2/SHO 22% 34% SHO3/SpR 16% 6% Consultant 5% - Crash team 5% 1%
  • 35. Discussion • SEWS is well utilised and understood by nursing staff in CAU – dedicated education program • Patients admitted to CAU routinely have observations monitored and SEWS calculated • Ongoing issues with calculating SEWS as part of routine ward observations
  • 36. Discussion • Patients triggering SEWS ≥4 tend to be seen sooner than those with SEWS <4 (ns) with 82% concordance to the 20 minute guideline – No difference between CAU and ward arc – No significant outcome effect seen with delay in review (but numbers small)
  • 37. Discussion • No significant differences in response time for patients SEWS ≥4 across the hospital • Significant differences arise between various specialty wards for patients with SEWS <4 but causing clinical concern – Important to remember that a proportion of these patients are still unwell with 11% requiring transfer to critical care – Only 50% had full SEWS measured
  • 38. Discussion • Patients triggering SEWS ≥4 are generally reviewed by more senior staff than those with SEWS <4 (ns) • The majority of clinical issues overnight are dealt with satisfactorily by doctors of SHO grade or below
  • 39. Recommendations • Current level of medical staffing in CAU appropriate to allow prompt review and satisfactory treatment of patients triggering SEWS ≥4 • CAU thus to remain autonomous and not be formally covered by H@N • SEWS education program to be broadened to encompass ward arc
  • 40. Current Status • Hospital at Night commenced October 2006 • 1 Specialist Registrar, 2 SHOs, 2 FY2s and 2 FY1s plus 3 SNPs (Senior Nurse Practioners) • Specialist Registrar also has supervisory capacity over 2 SHOs and 2 FY1s working in Combined Assessment
  • 41. Future Investigation • Repeat audit now underway to assess any changes in incident response times and clinical outcomes now Hospital at Night operational • Also audit broadened to include critical care, before and after the introduction of Hospital at Night
  • 42. Many Thanks • Professor Derek Bell, Professor of Acute Medicine, Imperial College, London • Dr Donald MacLeod, Consultant in Acute Medicine, Western General Hospital, Edinburgh • Ruth Paterson, Practice Development Nurse, Western General Hospital, Edinburgh
  • 43. References 1. p 2. Jarman B, Gault S, Alves B et al. Explaining the differences in English hospital death rates using routinely collected data. BMJ. 1999. 318: 1515-1520 3. 4. Silbergleit R, Kronick SL, Philpott S et al. Quality of emergency care on the night shift. Acad Emerg Med. 2006. 13: 325-30 5. Hilson SD, Rich EC, Dowd B et al. Call nights and patient care. J Gen Intern Med. 1992. 7: 405-410 6. Duke GJ, Green JV, Bredis JH. Night-shift discharge from intensive care units increases the mortality risk of ICU survivors. Anaesth Intensive Care. 2004. 32(5): 697-701 7. Tobin AE, Santamaria JD. After-hours discharges from intensive care are associated with increased mortality. 2006. Med J Aust.
  • 44. References 8. Schein RM, Hazday N, Pena N et al. Clinical antecedents to in- hospital cardiopulmonary arrest. Chest. 1990; 98: 1388-92 9. Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intens Care 1997; 8: 100 10. Subbe CP, Kruger M, Rutherford P et al. Validation of a modified Early Warning Scoring Score in medical admissions. QMJ. 2001; 94: 521-26 11. Royal College of Physicians of London. The interface between acute general medicine and critical care. Report of a working party of the Royal College of Physicians. 2002. 12. NCEPOD. An acute problem? 2005 13. Paterson R, Macleod DC, Thetford D et al. Prediction of in-hospital mortality and length of stay using an early warning system: clinical audit. Clin Med. 2006; 6: 281-3