What’s New in the Patient Safety World
Another Procedure to Avoid Late in the Day or on Weekends
Add yet another
procedure to the growing lists of procedures you don’t want done late in the
day or on weekends. In our October 2014 What’s New in
the Patient Safety World column “What
Time of Day Do You Want Your Surgery?” we discussed issues related to
laparoscopic cholecystectomies done after hours. In our September 2009 What’s New in the Patient Safety World column “After-Hours
Surgery – Is There a Downside?” we discussed adverse outcomes associated with doing certain types of orthopedic
surgery after hours. We think the issues raised are significant to almost every
type of surgery and probably other procedures as well.
So it should come as
no surprise that some non-emergent procedures done in the cath
lab or OR might also be problematic. Hsu and
colleagues (Hsu
2014) demonstrated in a large,
real-world population, that implantable cardioverter-defibrillator
(ICD) recipients implanted in the afternoon/evening and on weekends/holidays
more often experienced adverse events, particularly prolonged hospital stays.
Those patients implanted in the afternoon or evening had an 8% higher
likelihood of any complication and 29% higher likelihood of a prolonged
hospital stay. In-hospital death, however, was not increased.
In our previous
columns noted above (and the full list is at the end of today’s column) we’ve
discussed many of the factors contributing to problems for cases done after
hours or on weekends. Hsu and colleagues acknowledge that implantable cardioverter-defibrillator procedures performed later in
the day and on weekends/holidays may be associated with adverse events due to a
variety of factors including operator fatigue, handoffs, reduced staffing, and
limited resource availability.
But keep in mind
that this was not a randomized controlled trial. Rather it was a retrospective
review of a real-world population. Even though they adjusted their analysis for
a variety of factors, it is conceivable that there may be unrecognized
patient-related factors that led to cases being done late in the day.
Some of the
contributory factors may not be modifiable. However, others may be. For
example, if the cardiac electrophysiologist or
surgeon doing the implant perceives difficulty scheduling the procedure for the
following morning (or has a conflict with his/her own schedule that next
morning) he/she may push to do the procedure late on the current day.
Maintaining scheduling flexibility to accommodate such cases the next day may
be an important system fix.
Take a look at the
experience with ICD implantation at your own hospital. Because Hsu’s data came
from the National Cardiovascular Data Registry-ICD Registry™ you’ll likely find
similar patterns at your hospital.
Some of our previous
columns on the “weekend” and “after
hours” effects:
·
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”
·
August
2014 “The
Weekend Effect in Pediatric Surgery”
·
October
2014 “What
Time of Day Do You Want Your Surgery?”
References:
Hsu JC, Varosy PD, Parzynski CS, et al. Procedure Timing as a Predictor of
In-Hospital Adverse Outcomes from Implantable Cardioverter-Defibrillator
Implantation: Insights from the NCDR®. Amer Heart J
2014; Published Online: October 25, 2014
http://www.ahjonline.com/article/S0002-8703%2814%2900612-7/abstract
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