Death Doesn’t Wait for Weekends

[box] David Fisher dissects the recent furore over increased death rates at weekends [/box]

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Would you have a coronary artery bypass graft on a Friday 13th? What if you accidentally smashed a mirror on the morning of the operation? Would the sight of ravens precipitate a heart attack before walking through the hospital door? New evidence brings to light another concern which will strike fear into the hearts of surgical patients. Beware of the weekend.

A recent study published in the BMJ sought to establish whether the quality of medical care was inferior at the weekend as compared to the rest of the week. The team at Imperial College analysed data collected at the 163 English acute hospital trusts, looking specifically at the records for elective inpatient admissions over a 3 year period. They noted the day of the week the surgery was performed and whether mortality occurred within a 30 day period. It was hypothesised that mortality rates would be more pronounced among patients operated upon at the weekend and on Thursday and Friday because their critical 48 hour post-operative period, when serious complications are most likely to occur, would coincide with the weekend.

The results of the study were startling. The adjusted odds of death for an elective surgical procedure was 44% higher if the surgery was performed on Friday as compared with Monday and an even more disturbing 82% higher if carried out over the weekend. Perhaps less expected was the emergence of a linear trend of mortality correlating with the week’s progression. Monday was the safest day to have surgery. Tuesday was less safe, a 7% increase in the odds of death compared to Monday. Wednesday was even less safe, 15% more risk than Monday. The odds of death on Thursday were again increased at 21% more risk than Monday.

One possible explanation for the dramatically increased risk of mortality following surgery on the weekend is that patients needing weekend surgery might be more ill and therefore more likely to suffer from a complication. This could be supported by the fact that only 4.5% of elective procedures are performed at the weekend. However, this explanation does not withstand scrutiny. The study organisers used a mathematical model to calculate a score for each patient depending on the comorbidities. Interestingly, weekend patients often had less comorbidity, fewer recent admissions to hospital and underwent lower risk surgery compared to weekday patients. Having closed this avenue of enquiry, the authors offered one other possible reason for consideration. They suggested that the increase in mortality could be linked to reduced or locum staffing and poorer availability of services at the weekend.

Certainly the association between less comprehensive care at the weekend and mortality is plausible particularly when considered alongside other reports. The most recently published Dr Foster Hospital Guide asserted that mortality rates were higher for patients admitted at the weekend in English hospitals in 2012 compared to those admitted on a weekday. Additionally, hospitals with greater senior staff presence at the weekend have lower patient mortality figures. Pressing the dagger deeper into weekend elective surgeries, an editorial was published alongside this study. It questioned the sense of scheduling elective surgeries for the weekend, citing poorer outcomes as justification. This is surely a sensible and logical response to the results of the study but it ignores the primary problem.

Careful examination of the data reveals that the primary issue is a constant upward trend in the odds of death throughout the week. Reduced staffing at the weekend is incapable of explaining why a patient who has an operation on Tuesday is more likely to die than a patient who was operated upon on Monday. Further, it is inconsistent with the finding that Wednesday is a riskier day than both Monday and Tuesday. The spiking of the odds of death on Friday and the weekend is the most glaring part of the data but presumably represents a secondary factor, such as reduced staffing, which is compounding the primary problem.

The marked increase in mortality as a result of weekend surgeries and immediate post-operative recovery on the weekend is certainly an issue that ought to be scrutinised and addressed. Focussing complete attention on the weekend is however inappropriate. We should not bury our heads in the sand and pretend there is no other concern. Questions must be asked why there is a linear trend in mortality as the week progresses. More data should be accumulated. Is there a common cause of death? Perhaps a common cause could be linked to errors in medical care that become more frequent as the week progresses as staff become increasingly tired. What was the average amount of time the deceased patients spent recovering in hospital before being discharged compared with those who did not die? Maybe the pressure to vacate beds results in increasingly hasty discharge, particularly in the lead up to the weekend when few patients can be discharged.

We must tackle the issue of understaffing at the weekend but at the same time not hide from the fact that there is another unidentified problem. Further probing may reveal a hornet’s nest of issues and if so, it is vital we give it a stir.

Words by David Fisher
Illustration by Alexis Nelson

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