HECTOR: A PDA Based Clinical Handover System

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1 HECTOR: A PDA Based Clinical Handover System 1 Marilyn Rose McGee-Lennon, 2 Martin Carberry, 1 Philip D Gray 1 Department Computing Science, University of Glasgow, Glasgow G12 8QQ, UK 2 HECT Office, Hairmyres Hospital, East Kilbride, NHS Lanarkshire, Glasgow G74, UK {mcgeemr@dcs.gla.ac.uk, martin.carberry@lanarkshire.scot.nhs.uk, pdg@dcs.gla.ac.uk} Abstract. The European Working Time Directive [1] is beginning to have a profound impact on the delivery of out-of-hours services in hospitals throughout the UK. Three hospitals in Lanarkshire are pioneering a new approach to hospital emergency care, called HECT (Hospital Emergency Care Teams). A handheld computer system was developed to support organizational audit and clinical handover within these specialised HECT teams. This study reports on the evaluation of the HECT handheld system in order to establish both how the system was used by the nurses in practice and how well it was accepted within these new HECT teams. Positively rated features include the generation of a printed handover report and the facilitation of clinical audit. Negative outcomes included the potential of additional time required to input data on handheld devices. The results suggest that, if introduced properly, similar PDA based clinical handover systems could successfully be adopted by many other UK hospitals to allow successful health care under these new working time directives. The outcomes from this study could influence both the design of future handheld clinical support systems and the successful integration and evaluation of such systems into the healthcare environment. Keywords. Handheld computers, Mobile Computing, Hospital Emergency Care Team (HECT), Health Informatics, Critical Care Assessment, Clinical Handover. 1 Introduction In 2000, the European Working Time Directive (EWTD) stipulated that junior Doctors throughout Europe would have their working hours restricted by law to 58 hours per week in the first instance and then to 48 hours per week by 2009 [1]. In response to the EWTD and subsequent reduction in junior doctors hours, NHS Lanarkshire have implemented Hospital Emergency Care Teams (HECT) to provide out of hours emergency care on three District General Hospitals in NHS Scotland [2]. The HECT consists of a team of medical staff (two senior nurses and three senior house officers) who are responsible for the out of hours emergency care in NHS Lanarkshire s three acute hospital sites. The HECT nurse function is an innovative one and includes advanced clinical roles some of which could be supported by information technology solutions.

2 2 1 Marilyn Rose McGee-Lennon, 2 Martin Carberry, 1 Philip D Gray There is a continuing drive to utilise information technology in the development and modernisation of the NHS [3]. The NHS Plan advocated the use of information technology specifically to support the development of new roles [3] - such as HECT that are novel and innovative in the UK. The HECT nurses require very detailed operational data, covering the full range of the team's activities, in all hospital locations, 24 hours per day, seven days per week. This quantity of data lends itself to a computer-based solution for data capture for the HECT teams. The Department of Health stressed the importance of effective handover for hospital at night teams [4]. Clinical handover must include the prioritisation and review of sick patients that can help minimise clinical risk [4,5]. Handheld computer based support was identified as a way of potentially enabling these new HECT teams to carry out their jobs more effectively, including moving around the ward(s), reviewing sick patients and clinical handover. Consequently, a hand-held computer system (HECTOR) was designed for HECT use in order to support patient management, provide access to evidence based guidelines, inform decision-making, facilitate clinical audit and plan service development. The area of attempting to replace paper records in a hospital setting is rich with studies [e.g. 6, 7 ]. The HECT role and the HECTOR system in the context of acute care are novel however making it difficult to compare HECTOR to any existing work. Evaluation of such new NHS information systems is crucial if policy makers are to accept the success of systems and roll them out into NHS working practice. Moreover, user evaluations in the field are required in order to examine both the usability and acceptability of technology. Where possible, evaluation should include both a formative component with the intended users as the system is developed, and a summative evaluation in the appropriate working context. Effective and collaborative evaluation can improve acceptance by the users and adoption by the NHS. This study focused on a user-based evaluation of the PDA based HECT system in the three hospitals. The study facilitated the assessment of both the functionality and usability of the system in practice, it also determined user acceptance and identified the perceived benefits of the system. The evaluation was carried out over a four-week period in the three NHS hospitals using conventional mixed methods, specifically questionnaires and follow-up interviews with the HECT nursing staff users of the HECT system. The paper concludes with a discussion of the human computer interaction issues revealed through the study. The authors believe that these lessons learned might be useful for the future development and integration of computer based clinical handover systems into the healthcare environment. 2 The HECTOR Handheld System The Hospital Emergency Care Team Operational Record (HECTOR) is an innovative hand-held computer system developed collaboratively by Kelvin Connect Ltd and the HECT teams. The main features of HECTOR were chosen to support patient management, provide access to evidence based guidelines and patient information and facilitate advanced clinical audit. Due to the novelty of HECT and therefore the lack of comparison point, the operational features of HECTOR were informed by

3 HECTOR: A PDA Based Clinical Handover System 3 government policy that is clinical governance [5]. The final system features were also strongly influenced by the requirements of the HECT team during an iterative design phase. The HECT team involvement during this design phase also appeared to promote a perceived sense of ownership of the system by the team members. This could in part explain the 100% compliance rate throughout the study. HECTOR consists of (1) a set of PDAs running software for recording and reviewing clinical; data, (2) PC-based access to report generation, user and asset management, (3) a database server with which (1) and (2) communicate. Overall, the system intends to support convenient, rapid collection and analysis of very detailed concise operational data covering the full range of HECT activities. The initial communication uses simple docking with the potential to upgrade to wireless operation. All the system information is represented in XML and data storage and communication is protected by strong encryption. It is worth noting that although HECTOR is not a hospital Patient Management System (PMS) itself, the system would be suitable for integration with existing hospital PMSs. The HECTOR system services available via the handheld devices include: Clinical information capture at the bedside or on the move A task list component Reference information for clinical decision support Automated creation of printed shift reports Printed patient assessment at the bedside using mobile printers Detailed activity reports for service planning and monitoring Fig. 1(a). PDA Casebook Fig. 1(b). Assessment Document Both free text and fixed field entry can be used to enter patient and care data. Each patient record, (See Fig 1a and 1b) can be re-accessed by the nurse as well as accessed by the staff in subsequent shifts.

4 4 1 Marilyn Rose McGee-Lennon, 2 Martin Carberry, 1 Philip D Gray A main feature of HECTOR allows the generation, viewing, and printing of a shift report of all the relevant data entered or produced during a shift (See Fig 2). The system also contains a set of reference material that nursing staff can access at any time. HECTOR has been in continual use (24 hours a day) since the service began in August 2004, by 27 nurses at 3 sites. Fig. 2. PDA Shift Report 3 METHODOLOGY The HECT evaluation was carried out over a four-week period during July and August A within subjects (n=27) study of the pattern of use of the system and attitudes towards the system was conducted across the three District General hospitals. The primary hypothesis was that the system and its features are used effectively and perceived to be of benefit to the HECT work practice without added perceived time or workload. Qualitative and quantitative data was gathered from a questionnaire and follow-up interviews to address the following research questions: How do the HECT nurses use the system? - What features are used and how often? - What features are not used or used rarely? - Where and when is the system used? How is the system perceived by the nurses? - What are the perceived benefits of the system and each of its features? - What are the perceived problems with using the system? - What is the perceived workload of using the system? - What is the perceived impact on time? - What are the perceived effects on work practice of using the system?

5 HECTOR: A PDA Based Clinical Handover System Data Collection A questionnaire was constructed and used to gather data on how the HECT system was used within the emergency care team and the attitudes of the staff towards the system. The questionnaire used a combination of closed and open questions and a series of statements with a five point Likert scale to elicit responses. The Likert statements were influenced by previous studies evaluating the use of similar handheld computer systems in a health care setting [8] thus providing a degree of reliability and construct validity to the attitudinal measures used. Feedback from HECT nurses, the HECT project manager and the software company pre-pilot, also influenced choice of Likert statements, thus providing a degree of content validity [9]. Follow-up semi-structured interviews were conducted, approximately two weeks post questionnaire, with participants (n=5) randomly and independently selected from the questionnaire respondents. Interview structure was informed by the responses from the interviewees questionnaire. The HECT project manager was excluded from the sample in order to minimise bias. A Research Associate, and one of the authors, conducted the analysis and were not involved with the NHS or the Kelvin Connect. A covering letter was sent with the questionnaire to outline the research project, explain that participation was voluntary and give instructions as to how to complete the questionnaire and where and when to return it. The participants, all Registered General Nurses working in HECT, were mailed a self-report questionnaire approximately 10 months post HECTOR pilot. 4 Results and Discussion All 27 questionnaires were returned and analysed. Such a high response rate could partly be explained by the fact that the respondents (and those using the system) were an experienced senior clinical group who were heavily involved in the design and introduction of the HECT system. The questionnaire generated both quantitative and qualitative results. Frequency counts of responses were generally used to illustrate trends in attitudes from the questionnaires. The Likert style questions throughout the questionnaire generate scores which are non-parametric and which have been used to rank responses, for example perceived order of benefit rather than comparing absolute scores. Thematic coding was used to identify emerging themes and attitudes from the open-ended questions in questionnaires and interviews. Both are discussed here. Interview comments were used to further investigate the questionnaire results. Responses revealed that 62% (N=17) HECT staff used a computer several times per day and an additional 22% (N=8) used a computer at least several times per week. Broadly speaking then the majority of the user group were regular users of computers with the exception of the two members of staff who had never previously used computers. On the other hand, 72% (N=20) of the HECT staff had never used a handheld computer before. Although it would be interesting to compare the perceptions and attitudes of computer novices and experts, the small numbers in this study prevent any meaningful distinction for analysis purposes.

6 6 1 Marilyn Rose McGee-Lennon, 2 Martin Carberry, 1 Philip D Gray 4.1 Overall perceived experience with HECTOR The questionnaire presented a series of 5-point Likert style statements regarding the overall experiences with the HECT system. The set of statements were thematically clustered into the following subcategories - Ease of Use (6 questions), Effects on Time and Work Practice (4 questions), and Accessing and Sharing Information (4 questions). The individual responses were scored using the convention of assigning a numerical value (from 1-5) for each of the possible question responses (strongly disagree=1, disagree=2, neutral=3, agree=4, strongly agree=5). The mean aggregate scores for each theme were then calculated. These means can be compared to the maximum (strongly agree) and minimum (strongly disagree) possible score as well as the neutrality score, which would indicate that all respondents answered neutral. Actual Score Strongly disagree (min score) Strongly agree (max score) Overall score Ease of Use Effects on Time & Work Accessing & sharing Information Fig. 3. Likert-rated Experience with HECT system Neutral Figure 3 shows that the overall experience was positively rated. The subcategories revealed slightly more about the perceived experiences with the system. The ease of use of the system was rated as positive, as was the accessing and sharing of information. This is validated by the individual questions contained within the questionnaire regarding these issues. The Time and Work Practice issue however was rated negatively but with the score nearing neutrality. The HECT staff were also asked to rate the perceived workload of using the system along the factors shown in Figure 4. The highest possible score for any factor was 135 and a neutral score would be Thematic coding was used to identify emerging themes and attitudes from the open ended questions in the questionnaires and interviews. Both are discussed here. Interview comments were again used to validate or further investigate the questionnaire results. The results show that time is perceived as most problematic. There were also comments about workload made during interviews, including, I believe that the PDA does increase workload as I choose to write information on paper then make time to transfer data onto PDA.

7 HECTOR: A PDA Based Clinical Handover System 7 Aggregate Response Time 87 Frustration 65 Mental Effort 53 Performance 49 Physical Effort 30 Fig. 4. Perceived workload involved (0-135; 135 being highest perceived workload) Given the nature of implementing new systems into health practices this is an important finding. Duplication of work may have added time constraints and additional workload which might only be acceptable where the perceived gain is equal to or higher than this additional time or workload. It is worth noting that the overall perceived effects on time and work practice were not being expressed as significantly negative or detrimental (11.67 / neutrality 12) as might have been expected. This is of significant importance when these responses are viewed in context within the use of HECT. The system is often used during or after stressful emergency situations and therefore a far more negative perception on time, may have been expected. This may be the influence of other positive effects of the system balancing out any negative issues regarding time. This was highlighted by a number of respondents in the interview phase. One example highlighted the perceived benefit of data collection outweighing the negative impact of effect on time. In the short term PDA and HECTOR are time consuming, however for audit purposes data collection very helpful. The following results and discussion pertain to the perceived benefits of each of the individual HECT system features. 4.2 Perceived benefits of the individual system features Figure 5 shows the perceived usefulness or benefit of each of the individual system features to the nursing staff s work practice. The variation in scores was difficult to summarise and therefore a Likert-type score was used to assign each feature a usefulness or benefit score in order to determine the difference in perceived usefulness. Figure 5 shows the features ordered in terms of perceived benefit to work practice using these aggregated scores. Figure 5 shows that generating and printing the shift report are perceived as most beneficial while browsing the reference material and free text data entry were of less perceived benefit. These findings will be discussed in relation to the main system components detailed in section 2 (Clinical

8 8 1 Marilyn Rose McGee-Lennon, 2 Martin Carberry, 1 Philip D Gray information capture 4.2.1, Reference information for clinical decision support 4.2.2, and Automated creation of printed shift reports 4.2.3). Printing shift report 81 Generating shift report 79 Saving data 67 Handheld 66 Creating a document 66 Transferring to store 65 Data entry - fixed fields 64 Printing a document 64 Data entry - free text 62 Browsing reference material 62 Logging on 53 Fig. 5. Perceived benefit of feature to work (0=not, 54 =somewhat, always = 108) Clinical information capture Figure 6 shows the frequency of responses for the location of use of the system. More often than not, the nursing staff used the system in the office while they were stationary. This was reflected strongly in the questionnaire and interview responses. Sometimes this [data entry] was done retrospectively - again which could ease interruptions. Location Score Office 74 Stationary 73 On Move 57 Bedside 32 Fig. 6. Location of use of HECTOR (0=never, rarely=27, sometimes=54, often=81, all the time=108) Despite some staff filling in details on the move, it was pointed out by several of the staff during the interview that if they were too busy they would often have no choice but to wait until after their shift to sit down and use the system retrospectively. This

9 HECTOR: A PDA Based Clinical Handover System 9 could result in reduced compliance with data entry, as nurses would have to note interventions, recall them later and then enter data. It is not surprising that all nurses commented that they would usually take time after their shift to enter the data. This is likely due to the urgency of the situation and the patient intervention always superseding the requirements of data entry in an acute health care setting. This is validated in the low score for data entry at the bedside. These findings are interesting. In a clinical emergency it could be argued that it is unlikely that a mobile device will be used on the move, as design would imply (see section 5.2). In fact, the mobility of the device and how it can be exploited fully should be a matter for current and future mobile health informatics research Reference information for clinical decision support It also emerged strongly that the reference material on the HECT system was not used as often as expected. A total of 16 members of staff said that they accessed reference material, 10 staff did not, and 1 person did not respond. The interview data clarified the potential benefits of having reference material however it was in fact the content material that was of little perceived benefit. Many of the staff explored the reference material but did not feel the need to revisit the information in the process of working as it contained learned guidelines on what they already knew. For e.g. As aid memoir during early stages of HECT rollout, and A good aide mémoire to use on occasions but not used regularly. Inexperienced staff may benefit more from having simple guidelines on the system as reminder material as they are often working alone when acting as first responders. The interview data revealed more useful types of information that could be contained within the reference section such as detailed medical condition specifics, drug and rarely accessed blood test and titration references. For example: The system still has untapped utilities e.g. electronic references books, journals etc and Could contain more reference material drugs, blood results, Further work has now been done to incorporate this type of reference material in the form of education software onto the system. This type of reference material could support clinical decision making and should be investigated further Automated creation of printed shift reports The nurses were asked how they used the shift report facility. All the qualitative responses were thematically clustered by extracting themes from three independently generated categorisations of the interview comments. These themes are as follows: To review patients

10 10 1 Marilyn Rose McGee-Lennon, 2 Martin Carberry, 1 Philip D Gray At handover To communicate As evidence of workload Note taking Memory aid Carrying forward outstanding issues Aids verbal handover Reminder of patient location on ward Copy for medics Identifying higher risk patients It is clear from the evaluation that the shift report was a well-used facility, both by the individual user and the team, reiterating the importance of handover between teams and between members. This use of the facility is highlighted in responses from questions on the perceived benefits of the system: Preparing shift reports enables ALL members of the team to have up to date info on all the patients on the case book, and, Generation of the shift report is brilliant and saves a lot of time writing. Analysis of questionnaire and interview data show that shift handover was the most highly rated feature. This feature should therefore be considered for future systems. Many of the staff commented that the PDA casebook was useful to be able to look back at information at a glance while treating current patients. Furthermore, many of the comments refer to the use of the casebook as an aide mémoire, for information such as patient location, condition and treatment plans. This is a potential benefit when dealing with a hospital wide case load, especially when returning to a group of patients after a period of absence. Responses included: The Casebook is useful for cross checking where the sick patients were located and their presenting conditions and current treatment plan, 4.3 Other findings Activity reporting Throughout the questionnaire most of the respondents highlighted the benefit of the system as a means of collating data to support clinical audit. This was supported by the responses from the follow up interviews. Good record of interventions thus lending itself to audit data collection The use of the PDA alone has not influenced my practice. However I appreciate the need to audit our workload in order to improve/expand the service we provide.

11 HECTOR: A PDA Based Clinical Handover System 11 The benefit to the organisation in terms of clinical audit was not directly addressed in this evaluation. This was intentional, as emphasised by exclusion of the HECT Project Manager, and co-author of this paper, from the sample. This was to exclude organisation objective bias, as one of the rationales for the project was indeed the facilitation of clinical audit. However an emerging picture based on questionnaire and interview data highlighted the value of the system as a means of advanced clinical audit and this potential should be investigated further in similar systems. As discussed in section 1, clinical audit constitutes one of the main components of clinical governance and should be an operational objective of any new service [5] Additional Features Both the calculator and the diary/calendar function of the system were used frequently by some of the staff. One member of staff also commented that they adjusted screen brightness and other adjustable system settings. As these were not direct HECTOR features, they were not evaluated but it seems likely that certain handheld functions might be worth keeping enabled if they can be used to support work practices. Two people commented that it would be beneficial to be able to transfer data directly between handheld computers. This capability should be investigated further in future applications. It was also suggested that a wirelessly accessible printer (e.g., via Bluetooth) would be beneficial a feature which has since been piloted. Clinical assessments were generated and printed out by HECTOR then placed in the clinical notes. Feedback from this pilot was mainly positive but one negative aspect reported was the time taken to input the clinical data. This is an area currently being addressed by redesigning the assessment proforma to reduce input with no adverse effect on the clinical record. This is discussed further in the following section Problems Reported The printing of the shift report either never (N=12) or rarely (N=15) generated problems. Free text entry on the other hand did cause problems frequently for six of the users. This is not surprising considering that this remains an issue in the design of handheld input techniques. A possible reason for this being less than conclusive may be that staff adapted to the system to reduce problems, i.e. retrospective data entry to avoid problems inputting data o the move. Due to regular use of the PDA (24 hours a day, 7 days a week) the screen on the earlier models of PDA have a tendency to become less sensitive to touch entry over time. More recent models used in the latter part of the trial have proven far more robust and therefore this problem has been somewhat ameliorated. A similar issue, also reduced with the improvements in hardware in the newer models, is the problem of battery power. Earlier models had short battery life causing usability issues. This problem was overcome by the purchase of long life batteries, which provided the power needed for a 12-hour shift. It is clear from these results that, despite improvements in handheld technology, battery life and screen sensitivity are still important issues to be considered in mobile health informatics research. Since these problems only emerged after 3-4 months into the trial, the importance of longitudinal evaluation in the adoption of new technology is also highlighted.

12 12 1 Marilyn Rose McGee-Lennon, 2 Martin Carberry, 1 Philip D Gray 4.4 Future use for HECTOR Staff were also asked where else in the health setting they thought this kind of system could be used effectively. Some of the themes emerging from this question include the use in assisting in handover to another medical team or shift; keeping track of patient loads, and in the use of auditing patient/ward data, all key perceived advantages of HECTOR: It would aid better communication and could lead to a greater structured handover As well as this, the responses include different health teams such as community nurses, pain control nurses, cardiac rehab teams and discharge teams. It is a useful tool for auditing, therefore the majority of healthcare professionals would benefit from it. Included in the suggested benefits of systems like HECT therefore are clinical audit and medical handover facilities. These should be investigated further in mobile health informatics research. 5 Conclusions The results obtained from this study demonstrated the positive staff attitudes to the use of the HECT handheld computer system. This has been validated somewhat by the fact that other Scottish Health Boards have adopted the HECT system to support their hospital at night teams. The conclusions will focus on the main outcomes from the evaluation and specifically the value of the printed handover facility. These will be discussed in relation to the value to patients, staff, and the organisation, while recognising that all are interdependent and interrelated. 5.1 Value of the system to patients As illustrated in Figure 5, the handover report was perceived as the greatest benefit during the task of reviewing patients. This aspect of HECT provided staff with vital clinical information required to review sick patients and to follow up concerns and investigations requiring to be done. This may be of greater value when the nurse is reviewing the patient for the first time or following periods of absence, when an immediate update on their medical condition is required; however, we have no direct data on this from this study. The exact value to patients would have to be measured using clinical data that was out with the scope of this study. A point worth noting is that the majority of data entry appears to have been carried out when stationary and retrospectively (Figure 6). These findings highlight the need to investigate the appropriateness of data entry at the bedside in out of hours emergency situations and/or improved methods of data entry in these situations. In this case patient care remains the priority over data entry.

13 HECTOR: A PDA Based Clinical Handover System Value of the system to the organisation HECTOR was identified as an important aid to generating audit data. This is a new and innovative service. There is a professional requirement to measure and evaluate service delivery with specific emphasis on IT support [3,5]. The activity and search reports generated from the HECTOR database have influenced planning such as maintenance of professional standards, teaching, personnel resource planning and service redesign. The HECT system does not seem to have had a directly measurable effect on the management of the team workload, tracking tasks or general time management. Several interview comments suggested that the system would be of perceived benefit to the nurses if it could audit workload such that additional task load was recognized. 5.3 Value of the system to the staff and the team Findings from this evaluation have shown that the generation of a printed handover report has been perceived as a positive benefit for individual team members and the team in general. This is a recurring theme in both the qualitative analysis and quantitative analysis. The findings also show that HECTOR support for communication within the team was highly valued. These outcomes are in keeping with the reported recommendations from the Hospital at Night pilot sites project in England and Wales [4]. They emphasise the vital importance of hospital handover and the potential of information technology to support hospital at night [4]. The findings from this study have shown that the printed handover report provides a means by which the team can focus their attention on the sick patients during clinical handover. The reference material content was highlighted in the qualitative findings as being important to consider for future systems but in this case redundant to the HECT team. The benefits of reference material ultimately depends on the perceived value of that material to the individual practitioner and this feature should certainly be investigated further in the context of clinical decision support. Staff identified the negative factors of HECTOR as being the time taken to input data. The clinical value that the team placed on the printed handover and the facilitation for patient review appear to outweigh the negative effect of the time taken to enter the data on the system at present. This balance should continue to be evaluated in further similar health informatics research as perceived increased time and workload remains a potential barrier to many health informatics solutions. 5.4 Suggested improvements to the system Based on this study, more efficient data entry is an important potential improvement that could be made to HECTOR and similar systems. Refined pick lists for selection tasks have already been implemented as a relatively low cost improvement. Similarly, changes to work practice and the user interface have now been made which limit the need for free text entry. In the longer term, more fundamental changes to input techniques may be necessary, such as offering digital pen-based free text, digital

14 14 1 Marilyn Rose McGee-Lennon, 2 Martin Carberry, 1 Philip D Gray pen and tablet technology or the use of speech input. In addition, the reference material section of such systems should be constructed in collaboration with the intended users in order to reap any benefits. The systems wider potential for use in clinical and organizational audit should be explored further, as should the use of the system for specifically a medical handover as well as the team handover described. The primary hypothesis that the system and its features are used effectively and perceived to be of benefit to the HECT work practice without added perceived time or workload is upheld in part. The study findings have shown that HECTOR is perceived by the team as making a significant contribution to effective communication. The printed shift report in particular was found to facilitate effective clinical handover. Further findings also demonstrate the potential for such systems to support organizational audit. Although these combined benefits seem to outweigh the potential increase in time and workload in this study, time remains an important factor to consider in the introduction of IT solutions in the NHS. The authors believe that these findings could influence the future development and integration of computer based clinical handover systems into the healthcare environment. Acknowledgements. We thank NHS Lanarkshire and their staff for allowing the HECT PDA trial in their hospitals, Kelvin Connect for their technical support throughout, and the Burdett Trust for funding the evaluation. References 1. Council Directive. 2000/34/EC of the European Parliament and Council. Official Journal of the European Community. L195: 41-45; Carberry M. Hospital Emergency Care Teams (HECT): Our solution to out of hour s emergency care. Nursing in Critical Care. 2006; Aug. 11(4) Department Of Health. The NHS Plan. London. Stationary Office; Department Of Health. The implementation and impact of Hospital at Night pilot projects. An evaluation report. London. Stationary Office; Department of Health Great Britain. Clinical Governance: Quality in the new NHS. London. Stationary Office; Dick R, Steen E, Eds., The Computer-Based Patient Record, and Essential Technology for Health Care, Institute of Medicine, Smith R. What Clinical Information Do Doctors Need?, BMK, 313: , McGee MR, Gray PD. A Handheld Chemotherapy Symptom Management System: Results from a Preliminary Outpatient Field Trial, Journal of Health Informatics, Dec Polit DF, Hungler BP. Nursing Research: Principles and methods. 5th ed. Philadelphia: J B Lippincott; 1995