When I drop by a hospital on a weekend, I often see fewer cars in the employee parking lot than on a weekday. This is called "the weekend effect," which is a well-documented problem.
Simply put, there are fewer physicians and nurses to treat patients, and fewer technicians to operate life-saving equipment on the weekend. However, people don't have fewer medical problems on the weekend. They still have heart attacks, accidents and other emergencies, and there are plenty of patients admitted for elective procedures over the weekend.
So it doesn’t surprise me that there's a markedly higher death rate for patients admitted on the weekend — not just in the United States but in other countries as well.
A study in the July 6 issue of BMJ Quality & Safety looked at hospitals in the United States, United Kingdom, Australia and the Netherlands. It concluded that the odds of dying within 30 days of elective surgery were "significantly high" when it took place on the weekend, and "crude mortality" rates for weekend emergency admissions were higher in each location except Australia.
The authors of this study suggested that the higher death rate might be "specific to those diagnoses and procedures that are particularly sensitive to hospital services being reduced/absent on Saturdays and Sundays." That is, some of those missing cars in the parking lot may be those of technicians who operate some diagnostic equipment or life-saving devices.
Robert Glatter, MD, an emergency physician writing about this study in Forbes, suggested that the lack of services might include "treatment and management of cardiac arrhythmias, pulmonary emboli and heart attacks, as well as diagnosing rare conditions such as aortic dissection."
Also, there might be a problem with the caliber of personnel who will see you. The authors of the study speculated that "weekend patients may be subject to reduced and unsuitably skilled staff." That makes sense to me. As in any industry, the skilled people are allowed to choose when they can take time off, and of course they want to be off on the weekends.
Dr. Glatter interviewed Al Sacchetti, MD, an emergency physician in New Jersey, who said that residents and fellows account for most weekend coverage in academic medical centers and some community hospitals. "Junior housestaff may not only lack the clinical experience to make medical decisions," he said, "but also may not have the necessary clout to demand immediate diagnostic studies or access to the operating room or other specialized areas when needed."
In an industry like healthcare, where you are dealing with life and death issues, is it permissible to reduce the availability of services and use second-string staffing for two days of every week? Think about it – weekends amount to about one-third of the time hospitals are open!
The same phenomenon probably takes place during holidays like Christmas and Thanksgiving, and maybe even during the summer months, when some prominent doctors and nurses with seniority take their vacations.
The BMJ Quality & Safety study is not the only one to find unacceptably higher quality problems on the weekend. In a study that BMJ published in April, a researcher at the Yale School of Medicine found that even though there were fewer admissions on the weekends, hospital-acquired complications occurred at a higher rate – 5.7 percent, as compared to 3.7 percent on weekdays.
And that's not the only study. In a 2012 study in the Journal of Surgical Research, Johns Hopkins researchers found older adults with substantial head trauma were significantly more likely to die from their injuries over the weekend than during weekdays.
"There isn't a medical reason for worse results on weekends," one of the researchers for this study said in a release from Johns Hopkins. "It's more likely a difference in how hospitals operate over the weekend as opposed to during the week."
Holly S. Andersen, MD, a cardiologist NewYork-Presbyterian Hospital, told Dr. Glatter that patients hospitalized on the weekend also have a longer length of stay. "The time has come to determine the cause, rather than again prove its existence," she said.
I couldn't agree more. The need to deal with these quality issues is all the more urgent at a time when hospitals are being penalized for 30-day readmissions and are involved in accountable care organizations that aim for higher quality of care.
There are ways of counteracting the weekend effect, short of canceling weekend leave for senior hospital personnel. These methods were outlined in a recent study presented at the American Surgical Association meeting in April by statisticians at Loyola University Health System outside of Chicago.
Examining policies at 117 Florida hospitals and their outcomes for 126,666 patients, researchers concluded that by boosting specific services, hospitals could lower the rate of complications on the weekend.
These strategies involved raising the nurse-to-bed ratio, fully adopting EHRs and improving inpatient physical rehabilitation, home health and pain management.
Interestingly, simply hiring more staff — increasing the nurse-to-bed ratio — was not the most effective of these strategies. While hospitals that raised the nurse-to-bed ratio were 1.44 times more likely to overcome the weekend effect, the likelihood rose to 2.37 times for hospitals that had home health programs and 4.74 times for hospitals that fully adopted EHR.
I can understand the link between high-quality EHRs and better performance. A new shift coming in on the weekend needs to consult the patient's medical record as well as other sources.
The weekend effect has already been clearly documented in many studies finding higher rates of deaths and complications, and there are now specific strategies available to hospitals to counteract this deadly phenomenon.
Is anything being done about it?