Hospital at night revisited
Authors: Amir-Reza Jenabzadeh
Publication date: 15 Oct 2005
Amir-Reza Jenabzadeh checks out how the new system is bedding down
The hospital at night (HaN) programme was launched at the Middlesex Hospital and University College Hospital (UCH) on 27 September 2004. A diary  was published documenting the events of the first night of the new system. It is now almost a year since it has been in place and in this article I review its progress.
Hospital at night
The HaN team is a multidisciplinary team providing out of hours care for the inpatient wards at the Middlesex Hospital. A sister service exists at UCH. The Middlesex team is made up of a medical SHO, a surgical research fellow, an intensive therapy unit (ITU) specialist registrar (SpR), a patient emergency response team (PERT) nurse, and up to three night practitioners.
This new system has been adapted as a result of concern about the negative effects on junior doctors and their patients of traditional night-time working, and the need to reduce junior doctors' hours. The new team approach addresses the issues of continuity of care with documented patient handovers, and varying workloads between specialties. The improved communication among the team helps spread responsibility so that junior doctors do not feel so isolated, making it a much less stressful and enjoyable experience.
The day and night team meet in the handover room and all outstanding jobs are handed over. Particular patients of concern are highlighted and a management plan is discussed.
The day team depart and multiple copies of the handover sheets are made. The night team then divide up specific jobs. This evening one patient stands out on the surgical front and I make it my job to review him first. We arrange to meet at midnight.
I review a day one postop patient. The day staff had handed the patient over as becoming hypotensive just before the handover period. This patient had a moderately low haemoglobin in the morning and had been transfused a couple of units earlier in the day. Now he was beginning to develop hypovolaemic shock. I get the appropriate access, bloods, and fluid resuscitation. I try to contact the on-call SpR, but unfortunately he or she is scrubbed in theatre over at the UCH site.
While waiting for blood results and the SpR to finish in theatre I ask the ITU/HDU (high dependency unit) SpR to review the patient as I suspect he may have to go back to theatre.
I continue with a round of all the surgical wards, performing the less glamorous tasks like clerking patients who have been admitted late to the wards, prescribed emergency fluids, analgesia, and night sedation.
Blood results are back on my postop patient. The haemoglobin looks no better than it did this morning pre-transfusion. I return to the ward to see the orthopaedic and ITU SpRs reviewing the patient. They agree that the patient is still bleeding and needs to go back to theatre to stem the bleeding.
The appropriate consultants are informed of the events and the plan. The patient is moved to ITU/HDU to fully resuscitate pre-op and to prepare for theatre. Theatre sister is informed and she calls in the relevant theatre staff from home.
We have time before theatres are open and the patient is ready. I go to the midnight meeting. This has become a chance to catch up on the evening's events and a time when problems and solutions can be discussed between the team. I hand my bleep over to the night sister to mind while I am in theatre.
Finally get into theatre. Takes some time to identify the bleeders and stem the flow.
Scrub out and patient goes to ITU. I retrieve my bleep from sister. Beginning to hit the “quiet” part of the evening and all jobs on handover list are done. Now seems as good a time as any to have my power nap.
BLEEP... BLEEP... BLEEP. Patient on intravenous heparin needs new script as their infusion is about to run out. Great timing! I use this opportunity to cast an eye on our postop patient in ITU, who is doing well.
I am asked to review a surgical patient with chest pain. Thankfully the patient is not having an MI but I work my way through the chest pain algorithm.
Meet up in handover room. A dish full of half frozen buns almost makes it all worthwhile. We discuss events of that evening and I hand back the surgical patients to their appropriate teams.
- Jenabzadeh A-R. Hospital at night: diary of the first night. BMJ Careers 2004;329: 174. [Link] .
Amir-Reza Jenabzadeh clinical research fellow University College Hospital, London firstname.lastname@example.org