This month’s Journal of Bone and Joint Surgery has a very interesting article on adverse outcomes associated with doing certain types of orthopedic surgery after hours (Ricci 2009). We think the issues raised are significant to almost every type of surgery, not just orthopedic surgery.
The study was a prospective multicenter study, though not randomized. They looked at outcomes for surgery with intramedullary nail fixation for femoral and tibial shaft fractures. They sorted the patients into 2 groups: those done during “regular” hours (6 AM to 4 PM) and those done “after hours” (4 PM to 6 AM). Though there were no significant differences in fracture healing, infectious complications, or radiation exposure, the “after hours” group was associated with an increased need for reoperations for removal of painful fracture hardware. They note that this type of complication is more likely related to surgical technique than to characteristics of the fracture. They go on to discuss some of the potential factors that might be contributory.
We have previously seen increased mortality rates for cardiac surgery done after hours (unpublished data). We know you are thinking “obviously those cases that have to be done after hours are sicker so you’d expect a higher mortality”. That, of course, is true in many cases. However, we were very surprised to see how many cases that could have been delayed until “regular hours” were done “after hours” and the mortality rates in those cases were higher.
When you think about it, it makes sense. You are operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise as your regular daytime team and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. Our February 26, 2008 Patient Safety Tip of the Week “” discussed other adverse events occurring after hours in hospitals as well as in other industries and talked about the many potential contributory factors.
We highly recommend hospitals take a hard look at surgical cases done “after hours”. In particular, you need to determine which cases truly needed to be done after hours and, perhaps more importantly, which ones could have and should have been done during “regular hours”. If the latter are significant, you need to consider system changes such as reserving some “regular hours” for such cases to be done the following morning. You may have to alter the scheduling of cases for individual surgeons as well. For example, perhaps the surgeon on-call tonight should not have elective cases scheduled tomorrow morning. That way, if a case comes in tonight that should be done tomorrow morning you will have both a “free” OR room and a “free” surgeon. And you would need to develop a list of criteria to help you triage cases into “regular” or “after-hours” time slots.
The Ricci paper has done a great service in raising this issue. It’s one of those issues that “everyone knows about” but most have assumed that nothing can be done about. We hope that other researchers will take the lead and do similar studies for other types of surgery (and help develop the criteria for which cases could be delayed to daytime hours) but it’s time to be proactive at each of our hospitals and review both our historical data and our systems and capabilities. Lacking randomized controlled trials that demonstrate improved outcomes by deferring such cases to the next morning means we can’t apply a solid evidence-based approach at this time. But sometimes common sense needs to be applied while waiting for such studies to be done. At least take a look at the experience at your own hospital. We bet you’ll be surprised by the findings.
Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R. Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective Comparative Study. J Bone Joint Surg Am. 2009;91: 2067-2072