Night at the hospital

At night you sleep.

That’s the way it is meant to be.

People have been doing this for a very long time, except perhaps for those working night-shifts.

I have never been very good at shifting my sleep-wake pattern and when I was a junior doctor I didn’t so much struggle with the move from days to nights, but the switch back again. I think my circadian rhythm is a little slow.

Today I met a group of nurses, occupational therapists, doctors and a social worker to discuss night time – night in the hospital.

There is an assumption that when the lights go down and the night-staff appear on the scene that things become quiet and still – a little like a scene from Bambi.

It is true that most patients do manage to bed-down for the night, even though, in general it must feel strange – pretty unique really, in that they are trying to sleep on unfamiliar beds some of which make whirring or buzzing noises, but more peculiarly, there is no door to their room, or if there is a door, there isn’t a lock; (I am sure I can remember my grandfather jamming a tipped-over chair behind hotel doors, just to make sure no one would enter).

Sleeping in the hospital, with people coughing, snoring, shifting position, rough curtains separating you from others in the bay, often, confused old men – and, sometimes women, up and about, not getting to sleep, struggling to understand where the heck they are and what is going on.

Night in the hospital is a special place.

Night porters and doctors pad along silent corridors responding to their pagers; critically ill people are wheeled into the emergency department and transferred to intensive care or the operating theatre.

In the meeting we talked about the paucity of information that is conveyed about the night-time in hospital. During the day, there is often little documented in general, that is, unless something specific happens – a patient falls, they are assessed by a therapist or undergo a test; beyond that, much of it is down-time with no texture or detail.

Unusual behaviours are better tolerated during the day than at night – someone who is delirious, pacing the wards, looking for the way home, can be accommodated reassured or redirected – at night, the situation is different.

At night the hazards are greater – the potential to fall, the risk that you will be ‘medicated’ (given medicine to help you sleep which in turn can increase your risk of falling is greater); at night the lights are low and the obstacles abound – at night, there are fewer staff, fewer nurses and healthcare assistants so guide and support you.

Night is a special time when the unexpected or the unplanned happens, when lonesome doctors are left to sort those who have deteriorated.

And yet, in the documentation, for most hospitals across the country, during this period of time –between ten at night and six the next morning little is recorded other than – ‘asleep’ for those who are mostly asleep, ‘awake’ or ‘confused’ for those who don’t manage to settle-down.

On Mallard Ward, we recognised the importance of night times and night-time documentation and we have developed this into an art if not a science, detailing specifically what happens to our patients. On most wards, in most environments, night is a gap in the timeline.

We discussed the pitfalls of this lack of information – just think; we might spend as a health economy thousands of pounds on investigating, treating and caring for someone, only for it all to go wrong when they get home as we have underestimated the amount of support they require at night, or between the times that the carers pop in to check.

We tend to focus on something called ‘discharge’ that is, getting people home, concentrating on the demand for empty beds and flow within the system without considering that unless everything is in place a person will not manage, will not cope and likely deteriorate or fall and end-up back in hospital – I tend to think of this as – ‘Go direct to jail, if you pass Go do not collect £200’ – sigh. A no-frills readmission to hospital tends to be traumatic and almost always has worse outcomes.

The upshot of this meeting is a plan to work on this, to spread the good practice, to learn from one another more about the best ways to ensure that when we have invested time and effort, passion and love and care in the recovery of a person from a fall, a stroke or an infection, that we give them the best chance of success in returning home, to stay at home.

And if their nights are upside down, if for forty years they have been going to work at nine at night, we might need to adapt what we (that is, the system), can offer, after all, the work they did was probably hard and not something for everyone, which in all likelihood has allowed us to either sleep through the night or live through the day.

Let’s celebrate the night workers, those with insomnia or disturbed sleep and acknowledge that this really is just diversity in action.