We’ve already done numerous columns showing that adverse patient events and mortality are higher for patients admitted on weekends, commonly referred to as “the weekend effect”. We have also noted many studies demonstrating similar adverse occurrences in patients admitted at night so we sometimes lump weekend and night admission problems together as “the after-hours effect”.
A new study has looked at data from a large administrative database over the period 2002 to 2010 to determine the association between hospital-acquired conditions (HAC’s or “never events”) and admission on weekends vs. weekdays (Attenello 2015). They found that the incidence of HAC’s was 5.7% among patients admitted on weekends vs. 3.7% for those admitted on weekdays. Even after adjustment for a variety of patient, hospital, and severity cofactors they determined that weekend admission was associated with a 25% higher likelihood of developing at least one hospital-acquired condition.
Not surprisingly, the occurrence of a hospital-acquired condition was associated with a 76% higher hospital charge and an increased hospital length of stay (from a mean LOS of 4.53 days to 6.26 days). The authors recognize, however, that this LOS association does not necessarily imply causality and that it may be patients with longer LOS have more opportunity to develop a HAC.
Interestingly, patients with comorbid neurological conditions had a 35% increased likelihood of developing a hospital-acquired condition. This may be a reflection that patients with moderate to extreme loss of function were 34% to 157% more likely to incur a HAC (since loss of function is considerably more likely with many neurological conditions). It would be interesting to see how the HAC rates compared between hospitals with or without stroke center designation. We’d expect that those hospitals with coordinated stroke teams might have lower HAC rates. However, there is currently a widespread shortage of neurologists (and especially of neurologists available for night and weekend hospital call) that may be a contributory factor. On the other hand, delays in ancillary services (eg. CT, MRI, ultrasound) may impact patients with neurological conditions to a greater degree than other conditions.
The accompanying editorial (Dharmarajan 2015) discusses the difficulties of using data from large administrative databases to determine quality and safety outcomes, noting that estimates obtained from administrative data have never been convincingly validated against medical record data for many of the patient safety indicators. They make an argument that, instead of focusing on strategies to improve weekend care, we must focus on improving care every day of the week and overall strategies to prevent such adverse events.
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. Our healthcare systems clearly do not deliver uniform care 24x7. 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. And a difference in non-clinical staffing may be 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. 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 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 “ ” and May 4, 2010 “More on the Impact of Interruptions”).
Perhaps the most significant contribution of the current study by Attenello and colleagues is the quantification of the financial impact of HAC’s related to weekend admission. Since hospitals now (theoretically) bear the brunt of the cost of HAC’s, perhaps they will see that better upfront investment of resources may save money in the long run, not to mention result in better patient outcomes.
The weekend effect is complex and involves both patient-related factors and quality of care factors. While we may not be able to do much about the patient-related factors, there remains much we can do about the quality of care factors.
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 “”
· 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”
Attenello FJ, Timothy Wen T, Cen SY, et al. Incidence of “never events” among weekend admissions versus weekday admissions to US hospitals: national analysis. BMJ 2015; 350: h1460 (Published 15 April 2015)
Dharmarajan K, Kim N, Krumholz HM. Patients need safer hospitals, every day of the week. BMJ 2015; 350: h1826 (Published 15 April 2015)
A new study that demonstrated a significant positive impact of the WHO Surgical Safety Checklist on patient morbidity and mortality (Haugen 2015) seems to have touched off a debate on whether we are suffering from “checklist fatigue”. Haugen and colleagues, using a stepped wedge cluster randomized controlled trial at 2 Norwegian hospitals (one academic and one community), demonstrated that implementation of the Surgical Safety Checklist reduced complication rates from 19.9% to 11.5% (absolute risk reduction 8.4%). Moreover, mean hospital length of stay (LOS) was reduced by 0.8 days after the implementation. Mortality reduction from 1.6% to 1.0% overall did not reach statistical significance (though at the community hospital a mortality reduction from 1.9% to 0.2% was statistically significant).
The original introduction of the WHO Surgical Safety Checklist (Haynes 2009) was associated with striking reductions in both mortality and complication rates. However, that study and several others have come under some criticism because of their before-after study designs. And some studies, such as one done in Ontario, Canada (Urbach 2014) showed that implementation of surgical safety checklists was not associated with significant reductions in operative mortality or complications.
So the new study by Haugen and colleagues, using the new design (which is somewhat similar to crossover studies which you may be more familiar with in device or medication studies) should have been a welcome endorsement of the Surgical Safety Checklist. Indeed, in a commentary accompanying the study, several of the coauthors of the original WHO study were delighted that the new study showed support for use of the checklist (Haynes 2015). They pointed out that the Haugen study even showed a “dose effect” in that larger reductions in complications were seen when all portions of the checklist were followed.
But in a second commentary Stock and Sundt were less enthusiastic and raised the concern of “checklist fatigue” (Stock 2015). They note that checklists should be used judiciously, and are particularly useful to prevent memory lapses when a specific sequence of actions must be taken in order the same way each time. But they point out that such memory lapses actually are only involved in a small percentage of significant surgical incidents. They suggest we take a “timeout” before implementing any new checklist and see if it meets 3 criteria:
These are actually good criteria. We’ve done multiple columns on checklists (listed below) and described the ideal qualities of checklists in several of them.
The Haynes commentary also points out that the Norwegian study did several important things during its implementation. First, it modified the Surgical Safety Checklist to meet local needs. Second, they piloted it before widespread implementation, allowing for adjustments and for development of “champions” and “super users” who would be key players in further rollout. And, third, they did appropriate education for all disciplines affected when they did their widespread rollout.
We continue to be enthusiastic proponents of checklists. They need to be short and they don’t need to include a whole bunch of items that are seldom forgotten. And checklists are really good communication tools. So the wisdom of the criteria proposed by Stock and Sundt is well-grounded.
But perhaps a real lesson is that it is not simply enough to implement a checklist blindly based upon its successes in other venues. You actually need to measure after implementation to ensure it led to its intended effect and did not produce any unintended consequences.
Some of our prior columns on checklists:
Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Annals of Surgery 2015; 261(5): 821-828
Haynes A, Weiser T, Berry W, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360(5): 491-499
Urbach DR, Govindarajan A, Saskin R, et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014; 370(11): 1029-1038
Haynes AB, Berry WR, Gawande AA. What Do We Know About the Safe Surgery Checklist Now? Annals of Surgery 2015; 261(5): 829-830
Stock CT, Sundt T. Timeout for Checklists? Annals of Surgery 2015; 261(5): 841-842
Among our numerous columns on potentially inappropriate medication use in the elderly, we’ve done a few specifically on deprescribing (see our Patient Safety Tips of the Week for March 4, 2014 “Evidence-Based Prescribing and Deprescribing in the Elderly” and September 30, 2014 “More on Deprescribing”).
We always recommend that you do a “brown bag” medication reconciliation at least annually with all your geriatric patients in which you determine all the medications a patient is taking, including OTC drugs and supplements. The same can be done in a Medication Therapeutic Management (MTM) session with a pharmacist or nurse in other settings. You will always be surprised how many drugs are found to be duplicative or no longer necessary or potentially inappropriate and the opportunity to “deprescribe” presents itself.
But a new study from Australia points out that we often miss another ideal opportunity for deprescribing: the inpatient hospitalization (Hubbard 2015). They looked at patients aged 70 years or older admitted to general medical units of 11 acute care hospitals and, not unexpectedly, found that polypharmacy and hyperpolypharmacy were prevalent. However, significantly, they found that despite identification of multiple medications that might be considered potentially inappropriate almost no changes were made in the number or classification of medications.
Hubbard and colleagues note that the optimal setting for deprescribing is not clear. The inpatient setting typically has time constraints and the inpatient physicians may be much less familiar with the whole clinical picture than the outpatient physicians. Nevertheless, an inpatient hospitalization should be considered an opportunity to consider deprescribing.
In a related commentary several Australian healthcare professionals discuss the importance of better communication channels between all parts of the healthcare system (Mitchell 2015).
While it may be time-intensive, we believe that failure to do a thorough medication review with intent to deprescribe while the patient is an inpatient is, indeed, a missed opportunity. The inpatient physicians can arrange for a time to discuss the medications with the primary care physician. The inpatient hospitalization provides another unique opportunity. We’ve mentioned on numerous occasions that physicians almost never discontinue a medication they have prescribed even if it appears on Beers’ list or the STOPP list or equivalent list of potentially inappropriate medications. But here it is possible to say “things are different now” so we are going to take you off this medication.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Hubbard RE, Peel NM, Scott IA, et al. Polypharmacy among inpatients aged 70 years or older in Australia. Med J Aust 2015; 202(7): 373-377
Mitchell C. Polypharmacy a shared duty. MJA InSight 2015; Monday, 20 April, 2015
ECRI Institute has published its Top 10 Patient Safety Concerns for 2015. This year's list includes:
1. Alarm hazards: inadequate alarm configuration policies and practices
2. Data integrity: incorrect or missing data in EHRs and other health IT systems
3. Managing patient violence
4. Mix-up of IV lines leading to misadministration of drugs and solutions
5. Care coordination events related to medication reconciliation
6. Failure to conduct independent double checks independently
7. Opioid-related events
8. Inadequate reprocessing of endoscopes and surgical instruments
9. Inadequate patient handoffs related to patient transport
10. Medication errors related to pounds and kilograms
We can’t object to any of these being on the list and have done numerous columns on each topic. We’ll let you go to the ECRI Institute website where you can download their informative and useful document.
ECRI Institute. Top 10 Patient Safety Concerns for 2015
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