Patient Safety Tip of the Week
February 23, 2016 Weekend Effect
Solutions?
The “weekend effect” (sometimes also known as the “after
hours effect” since many of the same results apply to patients admitted at
night as well as on weekends) in which increases in mortality, complications or
adverse events are seen for patients admitted on weekends has been demonstrated
for a wide range of both surgical and medical conditions. Our numerous previous
columns on this issue are listed at the end of today’s column. Several more
studies on the phenomenon have been published since our last column.
While the “weekend effect” has been demonstrated for a
variety of medical conditions, it is not universal. One recent study showed
that children admitted to Scottish hospitals on the weekend were not more likely to die than those
admitted on weekdays (MNT 2015). Those
admitted on weekends were even less likely to be readmitted than those admitted
on weekdays.
But several other studies demonstrated the “weekend effect”
for other conditions. A recent study from the UK (Robinson
2015) found that in-hospital cardiac arrests attended by the
hospital-based resuscitation team during nights and weekends have substantially
worse outcomes than during weekday daytimes. The authors concluded that organizational
or care differences at night and weekends, rather than patient case mix, appear
to be responsible. Those results from the UK are quite similar
to those from a study in the US (Peberdy
2008).
A recent large study in the UK (Palmer 2015) suggested that
babies born at the weekend had an increased risk of being
stillborn or dying in hospital within the first seven days and that there were
also increases in the rates of other complications for both women admitted and
babies born at weekends, with higher rates of puerperal infection, injury to neonate,
and three day neonatal emergency readmissions. However, numerous rapid
responses (rapid responses
2015) submitted after the publication have challenged the methodologies
used in the study.
And yet another Scottish study demonstrated that stroke patients
admitted on weeknights or weekends/holidays missed more guideline-recommended
interventions and had higher mortality rates and fewer discharges to home (Turner
2016). Though those admitted on weeknights or weekends/holidays had
comparable rates of early cerebral scanning and thrombolysis (after
adjustments), they were less likely to receive swallow screening on the day of
admission or be admitted to a stroke unit on day 0 or day 1. Mortality rates at
7 and 30 days were higher in those admitted on weekends.
And a paper presented at the American Society of Nephrology
Kidney Week 2015 conference found that kidneys that would normally be made
available for transplantation were less likely to be procured from donors over
the weekend, and organs procured during the weekend were more likely to be
discarded than kidneys procured on other days (ASN
2015).
One recent study suggested that specific hospital resources
might be used to overcome the “weekend effect” seen in urgent general surgical
procedures (Kothari
2015). Researchers identified emergent/urgent surgeries (appendectomies,
cholecystectomies, and hernia repairs) in the HCUP database for Florida from
2007 to 2011 and used as a surrogate for the weekend effect an extended median
length of stay on the weekend compared to weekdays. They identified 17 out of
166 hospitals that did not exhibit the “weekend effect” and looked to see how
these hospitals differed from the others. Patient level factors like
socioeconomic status did affect the occurrence of the weekend effect but
hospital characteristics had more important associations with the weekend
effect. They found that hospitals not
having the weekend effect were more likely to have higher nurse-to-patient
ratios, full adoption of electronic medical records, home health programs, pain
management programs, and inpatient physical rehabilitation. The authors hypothesize
that the improvement in the weekend effect at some hospitals is a result of “the
ability of the identified components of perioperative infrastructure to assist patients
with increased discharge needs, improve transitional care, and ensure care continuity
from the week to the weekend”.
The study, of course, is limited by its use of
administrative data and use of a proxy for the weekend effect. Also, the nurse
staffing ratios were averages and did not specify whether such differed on
weekends. Also questioned is why 3 procedures that typically have very low
mortalities were chosen. Also, these are associations and may not play a causal
role. But are they plausible contributory factors? They certainly could be. Previous
work shows that the weekend effect is complex and involves both patient-related
factors and quality of care factors (see our November 2013 What's New in the Patient Safety World column “The
Weekend Effect: Not One Simple Answer”) While we may not be able to
do much about the patient-related factors, there remains much we can do about
the organizational and quality of care factors.
In our many previous columns on the weekend effect or
after-hours effect we have pointed out how hospitals differ during these more
vulnerable times. 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.
We’ve often said the use of the simple nurse:patient staffing ratio on weekends may be
misleading. That is because there is often a significant difference in nurse
workload on weekends. We’ve described the tremendous increase in nurse
responsibilities on weekends due to lack of other staff (no clerical staff,
delayed imaging, physicians not on site) that add additional responsibilities
to their jobs. 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 often 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. Even
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.
They may even end up doing some housekeeping chores and delivering food trays.
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”). We thus think that simply addressing nurse:patient staffing ratios
without addressing nurse workload issues may be short-sighted.
It is clear we have not yet achieved the desired state in
which our systems of hospital care are equivalent all hours of the day or all
days of the week. Add to this the increase in acuity or severity for patient
requiring weekend or after-hours admission and it is not surprising that we see
less desrirable outcomes in those situations.
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”
·
August
2014 “The
Weekend Effect in Pediatric Surgery”
·
October
2014 “What
Time of Day Do You Want Your Surgery?”
·
December
2014 “Another
Procedure to Avoid Late in the Day or on Weekends”
·
January
2015 “Emergency
Surgery Also Very Costly”
·
May 2015
“HAC’s
and the Weekend Effect”
·
August
2015 “More
Stats on the Weekend Effect”
·
September
2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
References:
MNT (Medical News Today). Patients not more likely to die at
weekends, say researchers. Medical News Today 2015; November 27, 2015
http://www.medicalnewstoday.com/releases/303265.php
Robinson EJ, Smith
GB, Power SG, et al. Risk-adjusted survival for adults following
in-hospital cardiac arrest by day of week and time of day: observational cohort
study. BMJ Qual Saf 2015;
Published online first December 11, 2015
http://qualitysafety.bmj.com/content/early/2015/12/11/bmjqs-2015-004223.short?g=w_qs_ahead_tab
Peberdy MA, Ornato JP, Larkin GL, et al. Survival
from in-hospital cardiac arrest during nights and weekends. JAMA 2008; 299: 785-792
http://jama.jamanetwork.com/article.aspx?articleid=181485&resultClick=3
Palmer WL, Bottle A, Aylin P. Association
between day of delivery and obstetric outcomes: observational study. BMJ 2015; 351:
h5774 (Published 24 November 2015)
http://www.bmj.com/content/351/bmj.h5774
rapid responses
http://www.bmj.com/content/351/bmj.h5774/rapid-responses
Turner M, Barber M, Dodds H, et
al. Stroke Patients Admitted Within Normal Working Hours Are More Likely to
Achieve Process Standards and to Have Better Outcomes. J Neurol
Neurosurg Psychiatry 2016; 87(2): 138-143
http://jnnp.bmj.com/content/87/2/138.full?sid=7caf47d3-6d0a-415a-84ed-87395f30bebf
ASN (American Society of Nephrology). Donor Organs May Be
Discarded Due to “Weekend Effect” at Hospitals (press release). Newswise 2015; November 7, 2015
http://www.newswise.com/articles/donor-organs-may-be-discarded-due-to-weekend-effect-at-hospitals
Kothari AN, Zapf MAC, Blackwell RH, et al. Components of
Hospital Perioperative Infrastructure Can Overcome the Weekend Effect in Urgent
General Surgery Procedures. Annals of Surgery 2015; 262(4): 683-691
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