In the modern economy, many industries, such as aviation, retail and manufacturing, no longer slow down over weekends. Yet hospitals have mostly resisted this trend, even though demand for many forms of health care is no less on weekends than on weekdays.
While most hospitals are open every day of the week, many operate with substantially reduced staffing levels on holidays and weekends.
A typical internal medicine ward at a teaching hospital in Ontario, for example, might function with only one-third of the doctors on the weekend that it would have on a weekday. And the most senior of these doctors will have left the hospital by early afternoon. Allied health professionals (such as physiotherapists and dieticians) are often also absent on weekends, with only nurses staffed in numbers that are comparable to weekday staffing levels.
It is understandable that health care professionals do not wish work over the weekend, but evidence points to a concerning “weekend effect” at hospitals: a small but meaningful increased risk of death associated with a hospital stay on a weekend versus a weekday.
Is it time for hospitals to start staffing at the same level all week?
The “weekend effect”: a small but meaningful increase in the risk of death
Nearly 12 years ago, Canadian researchers published a study in the New England Journal of Medicine, looking at nearly four million hospital admissions over a ten year period in Ontario. Their findings were the first large-scale documentation of what has come to be known as the “weekend effect”: for some health conditions, there is a small increase in the risk of death if a patient is admitted to hospital on a weekend rather than a weekday. Having controlled for patient characteristics, severity of illnesses, and types of conditions, the researchers concluded that the increased risk of death on the weekend was most likely due to decreased weekend staffing.
This study briefly broke into popular consciousness, remembers Chaim Bell, a physician and researcher at Mt. Sinai Hospital in Toronto and one of the authors of the paper. “For a few weeks I was doing interviews on CNN and all the US news outlets.” Asked why so little has changed since the publication of the paper, Bell remarks “probably a few reasons, but history is a funny thing – the last interview I did about the study was September 10th, 2001. Health care wasn’t really in the news for a while after that.”
But a new article in the British Medical Journal suggests that the “weekend effect” is still a reality, despite falling out of the popular consciousness. This study looked at the over four million elective surgeries performed in the United Kingdom between 2008 and 2011. The researchers found that that the risk of death after an elective surgery increases incrementally every day after Monday, with a 49% increased risk of death if the surgery is performed on a Friday, rather than a Monday.
The authors of this study suspect that the higher risk of death is tied to hospital staffing on weekends. “The first 48 hours after an operation are often the most critical period of care for surgery patients,” explained Paul Aylin, the researcher from the Imperial College London who led the study, in a statement. The increased risk may therefore be due to these critical 48 hours falling on a weekend, when staffing is lower.
A note of caution: interpreting evidence about increased risk
While these studies raise important questions, it is important to avoid exaggerating the risk of a weekend surgery or hospital admission.
First, Bell notes that while the relative risk of death associated with a weekend hospitalization is higher, the absolute risk is still very, very small. Relative risk refers to the extra risk on a weekend when compared to a weekday. Absolute risk refers to the actual number deaths on a weekend. For example, the risk of death after an elective surgery on a Monday is extremely low (about 5.5 in 1000), so even if the relative risk of having that surgery on a Friday is 49% higher, the absolute risk on a Friday is still quite low (about 8 in 1000). Put another way, if 370 patients had their surgery on a Friday instead of on a Monday there would be one extra death.
It is also important to note that these studies are observational, rather than randomized control trials. So while both studies looked at roughly four million hospitalizations, it was impossible for them to control for all variables. It is therefore possible that something other than weekend staffing levels was responsible for the increased risk – for example, perhaps better surgeons are more likely to operate on Mondays rather than Fridays. For these reasons, it cannot be known with certainty whether increasing weekend staffing would reduce the risk of death associated with a weekend hospitalization.
Finally, not all hospital departments are the same. Some units, particularly those that care for the sickest patients – intensive care units and emergency departments, for example – are often staffed very similarly on weekends and weekdays, or even increase staff on weekends.
While these cautions are important, Tom Closson, former CEO of the Ontario Hospital Association points out that the evidence we do have should be enough to prompt a thoughtful public debate about whether it’s time for hospitals to have more staff on weekends.
Reduced weekend hospital staffing sends ripples through the system
There are other consequences of lower weekend staffing at hospitals. Mina Tadrous, a community pharmacist who works many weekends, says low weekend staffing in hospitals disrupts continuity of care.
Patients frequently visit her pharmacy on Saturday mornings after being discharged from hospital on a Friday. Since the doctors who treated them at the hospital are rarely working on Saturday, Tadrous is often forced to manage errors in dosing, medication interactions, non-availability of prescribed medications and missing documentation without being able to consult with the prescribing doctors. “Many of these patients are very complex – they’re on a lot of different medications – there can be big disruptions until they can see their family doctor a few days later,” she says.
Low staffing on the weekend can also contribute to inefficiencies within hospitals. Bell notes that fewer doctors and virtually no allied health professionals over the weekend means that there is often a delay in discharging patients over the weekend.
This is especially true when patients must wait for a procedure before they can be discharged. “Many procedures aren’t done on the weekend, so if a patient is admitted on a Thursday, they sometimes have to wait until Monday before they can get discharged,” says Bell. This can create significant disruptions throughout the hospital, including backlogs in the emergency department.
Resistance to change
While the increased risk to patients and the ripple effect of low weekend staffing might seem serious enough to warrant change, Bell notes that so far these have not been enough to create a “burning platform” for reform.
This may be in part because the deaths associated with reduced staffing are so-called “statistical lives”. It usually cannot be determined whether someone who died would have lived if there had been another doctor or physiotherapist on the ward. It is therefore difficult to definitively connect specific deaths on weekends with reduced staffing levels. In the absence of definitive connections to specific deaths, it can be difficult to motivate change, particularly costly changes such as increasing hospital staffing.
Adding to the challenge is that many health professionals are not accustomed to working regular weekends, and like many of us, would prefer to have their time off fall on weekends, rather than weekdays.
And in practice, some health professionals do appear reluctant to change. In an effort to increase the efficiency of its surgical services, The Ottawa Hospital implemented a number of reforms to reduce the day-to-day variability in its elective surgery case load. One of proposed reforms was to move from a five-day schedule to a six-day schedule, with ORs open for elective surgery on Saturday. Since doctors are not hospital employees, it is difficult for a hospital to make a major change like this unless doctors are in agreement.
“When we presented the idea of a six-day pilot to our OR staff, nursing was mostly supportive and surgeons were of mixed opinion but agreed to proceed. However, the anesthesiologists were not prepared to support such a change at this time,” says Paula Doering, a Senior Vice-President for Clinical Programs at the hospital. Doering added that all OR staff have agreed to re-visit the concept in the future.
However, opposition among doctors is not universal. Alan Forster, a doctor and researcher also at The Ottawa Hospital reports that the hospital’s internal medicine unit has moved to a system where they have the same staff physician coverage on weekends as they do on weekdays. The change has not yet been formally evaluated, but Forster believes the number of weekend discharges has increased and he says the team feels patients are now getting higher quality of care on weekends compared with the old model.
A complex issue – change may have “unforeseen consequences”
“Weekend mortality is a complex issue, and complex issues very rarely have simple solutions,” cautions Mark Macleod, Chair of the Medical Advisory Committee at London Health Sciences Centre and former President of the Ontario Medical Association. “This is an important area to debate, but if we rush too much to try to fix it, we might create unintended consequences.” For example, he notes that if weekend workload was increased without also expanding the workforce to handle the increase in work, morale might suffer and burnout among health professionals could become more common.
When any major change is being proposed, caution is warranted. While the evidence of a “weekend effect” is reasonably strong, there is not yet enough data to know whether simply adding staff on weekends is the solution. Any large scale change would also require consideration of new scheduling models and how many new staff would need to be recruited in order to avoid negatively affecting the quality of life of health care professionals. In addition, change of this scale would have an impact on hospital and health system budgets.
Nevertheless, the evidence indicates that the status quo is putting some patients at risk. While studies suggest that the absolute risk of a weekend hospitalization to individuals patients is small, the cumulative effect is not: in the UK, for example, if elective surgeries on Fridays could be made as safe as those on Mondays, hundreds of lives might be saved every year.