What’s New in the Patient Safety World
August 2014
The Weekend Effect in Pediatric Surgery
The “weekend
effect” in which mortality and complications occur more frequently in
patients admitted on weekends or operated upon on weekends compared to weekdays
has been reported for multiple conditions. Various studies have
demonstrated higher mortality rates for patients admitted on weekends with
strokes, atrial fibrillation, diverticulosis surgery, a
variety of other surgical procedures, head trauma, COPD, CHF, perinatal events,
ICU admissions, ESRD, and other conditions. Note that we sometimes use the term
“after hours effect” since some of
the same issues occur in patients admitted at night.
Now a new study demonstrates the “weekend effect” also affects children undergoing surgery (Goldstein
2014). The researchers analyzed data over a 22 year period and noted that
children who underwent urgent or emergency surgery on weekends were 63% more
likely to die and 40% more likely to have complications than comparable
patients operated upon on weekdays. They were also 15% more likely to receive
blood transfusions. The surgeries analyzed were common surgeries (abscess drainage, appendectomy, inguinal
hernia repair, open fracture reduction with internal fixation, or
placement/revision of ventricular shunt) and the above findings were found even
after adjustment for patient characteristics. While the absolute numbers of
death were actually quite small the study does suggest that many of the same
factors which come into play in adults also impact children.
The study did not
determine which specific factors were responsible for the “weekend effect”. Our
November 2013 What’s New in the Patient Safety World column “The
Weekend Effect: Not One Simple Answer” highlighted a study from
Australia (Concha
2013) which showed that for most of the DRG’s showing excess
mortality with weekend admission there are both
patient-related factors and care-related factors in play.
We’ve discussed many of the contributory factors in our many
columns related to the weekend effect (see list at the end of today’s column).
Our healthcare systems clearly do not deliver uniform care 24x7. The differences
between the hospital during weekday daytime hours and the hospital at night and
on weekends is striking. Staffing patterns (both in terms of volume and
experience) are the most obvious difference but there are many others as well.
Many diagnostic tests are not as readily available during these times.
Physician and consultant availability may be different and cross-coverage by
physicians who lack detailed knowledge about individual patients is common. You
also see more verbal orders, which of course are error-prone, at night and on
weekends. But we’ve also argued that often it is a difference in non-clinical staffing that is a root cause. Our December 15, 2009
Patient Safety Tip of the Week “The
Weekend Effect” discussed how adding non-clinical administrative tasks to
already overburdened nursing staff on weekends may be detrimental to patient
care. Just do rounds on one of your med/surg floors
or ICU’s on a weekend. You’ll see nurses answering phones all day long, causing
interruptions in some attention-critical nursing activities. Calls from
radiology and the lab that might go directly to physicians now go first to the
nurse on the floor, who then has to try to track down the physician. They end
up filing lab and radiology reports or faxing medication orders down to
pharmacy, activities often done by clerical staff during daytime hours. In
those facilities that have CPOE, nurses off-hours
often end up entering those orders into the computer because the physicians are
off-site and are phoning in verbal orders. You’ll also see nurses giving
directions to the increased numbers of visitors typically seen on weekends.
Nurses even end up doing some housekeeping chores. All of these interruptions
and distractions obviously interfere with nurses’ ability to attend to their
clinically important tasks (see our Patient Safety Tips of the Week for August
25, 2009 “Interruptions,
Distractions, Inattention…Oops!” and May 4, 2010 “More
on the Impact of Interruptions”).
For surgery there are even other considerations. Not only
might the surgeon and anesthesiologist be called in from other activities but
the OR team of nurses and techs are also often called in from other activities.
Often the surgeries are performed by teams that are not used to working
together. Though we are unaware of any published studies on environmental
issues that might impact the weekend effect, we suspect that there might be
factors related to equipment, sterilization procedures, overall cleanliness, OR
temperature and humidity, and others that conceivably might differ on weekends.
To fix many of the above potential contributing factors
would obviously require considerable resources, both financial and human. In our November 2013 What’s
New in the Patient Safety World column “The
Weekend Effect: Not One Simple Answer” we made a business case that cases
prone to the weekend effect are likely more costly to hospitals (eg. complications are usually associated with increased
lengths of stay and utilization of more tests, medications, etc.). So there is
likely a return on investment (ROI) for resources spent alleviating some of
these factors.
The “weekend effect”
is a complex one, not easily amenable to one solution.
Some of our previous
columns on the “weekend effect”:
·
February 26, 2008 “Nightmares….The
Hospital at Night”
·
December 15, 2009 “The
Weekend Effect”
·
July 20, 2010 “More
on the Weekend Effect/After-Hours Effect”
·
October 2008 “Hospital
at Night Project”
·
September 2009 “After-Hours
Surgery – Is There a Downside?”
·
December
21, 2010 “More
Bad News About Off-Hours Care”
·
June
2011 “Another
Study on Dangers of Weekend Admissions”
·
September
2011 “Add
COPD to Perilous Weekends”
·
August
2012 “More
on the Weekend Effect”
·
June
2013 “Oh
No! Not Fridays Too!”
·
November
2013 “The
Weekend Effect: Not One Simple Answer”
References:
Goldstein SD, Papandria DJ, Aboagye J, Salazar JH, et al. The “weekend effect” in
pediatric surgery — increased mortality for children undergoing urgent surgery
during the weekend. Journal of
Pediatric Surgery 2014; 49(7): 1087-1091 July 2014
http://www.jpedsurg.org/article/S0022-3468%2814%2900005-0/abstract
Concha OP, Gallego B, Hillman K, et al.
Do variations in hospital mortality patterns after weekend admission reflect
reduced quality of care or different patient cohorts? A population-based
study. BMJ Qual Saf 2013;
published online 25 October 2013 doi:10.1136/bmjqs-2013-002218
http://qualitysafety.bmj.com/content/early/2013/10/22/bmjqs-2013-002218.full.pdf+html
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