Fewer hospital staff on weekends puts some patients at risk

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.

Should hospitals have the same level of staffing on weekends that they do on weekdays?

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  1. William barclay

    Lives are important 7 days a week. Less care on weekends is a callous attempt to save a few bucks. The premiers office should not have the power to change health care at will.

  2. Chris Carruthers

    There should be a significant increase of all professional weekend coverage. Better care. Ontario’s new funding formula is driving change and quickly. For example if under QBP funding they will pay for a max of 6 days care you cannot provide the patient with reduced care on the weekends or two days of the six. Similarly empty beds now are a loss of revenue. More patients will be admitted on the weekends and they will need the same supportive care on these days as week days. Professionals will find these changes difficult but reality is here.

  3. Dominick Amato

    What about countries (e.g., Israel, Iran, Arab countries) whose weekends are slightly different ? Are the figures comparable, i.e., shifted one day before or after?

  4. Katey Knott

    Even though the absolute risk of death is ‘very very small’, there are still important outcomes to consider, for instance, readmission rates or the patient experience. Would be interesting to see if patients feel differently about their preparedness for discharge, or the coordination of their care depending on when they had their surgery. My guess is probably.

  5. Michael Wosnick

    I would argue that it may be appropriate to have MORE staff on weekends. Weekends and holidays put extra pressure on ER and similar services when people do not have as much access to their family physicians (assuming they have one of course). That creates a domino effect since many of the medical staff get called to ER and acute care and urgent care etc for consults and are not even available to those who have already been admitted. Plus, the ER backlogs mean that a large number of patients who have been technically admitted but still languish on gurneys in the ER waiting for a bed.

    Unfortunately I have much experience on the patient side of things – it always seemed that parents and in-laws never failed to have their medical crises on weekends and holidays and I can tell you that it was sometimes a brutal experience to get any level of care.

  6. Brian Orr

    There is no question that the growing demand for hospital-based health care services, increasing expectations for quality care will pressure hospitals, and health care reform will pressure hospitals to look at expanding the utilization of hospital facilities during evenings on week days and on weekends. Based on my investigation of what is required to expand hours of service in a hospital, I can confirm that it is a highly complex issue with a wide range of unexpected consequences. One of the challenges is maintaining operational of clinical services because of a number of factors. One factor is the challenge of maintaining operational efficiency as there needs to be a growth in care demands to match the increase in hours of service. A second factor is that staff becomes more difficult and complex when expanding services beyond 5 days per week. A third factor is that many services are interdependent. For example a clinic may need to have the pharmacy and lab services available whenever the clinic is open. Hence efforts to expand the operational hours of one service can result in the need to expand a range of supporting services. On the people side it needs to be recognized that to staff one full-time hospital position for 24 hours/day, 7 days/week, 365 days/year takes about 5 1/2 employees, which is one of the drivers to limit the number of staffed positions at night and on weekends. Even to operate a service 8 hours/day, 7 days/week takes an increase of at least 40% in staffing compared to operating for 5 days/week. Such increases in staffing need to be matched with a matching increase in patient volume and funding.

    More uniform staffing and availability of services will increase over time, but it will be an evolutionary process.

  7. jimmy g

    Dollars to donuts your ER wait times will go down especially if you put more docs on there too (in addition to the allied health staff).

  8. Leslie Farney

    Hospital CEO’s are the highest salaried people in NY’s Mid Hudson Region as per Middletown, NY’s Times Herald Record’s annual survey/reportage and this likely holds true in any community. No one knows why, since we all know the quality and quantity of care is not a determining factor. Capitalism’s ‘bottom line’ are the profits taken-in for the shareholders, based on the life and death, pain and suffering of those who enter the hospital and are often kept there and/or are forced to be repeat customers of lengthy stays, due to inadequate and/or inappropriate care. More Americans die in hospitals due to medical error/malpractice (250K per yr.), than for any other illness, disease or reason. Hospitals are often the largest corporations in any community, with wealthy special interests who legally bribe our elected officials into a ‘code of silence’ with their campaign contributions. As a result, nothing is ever said or done about the agony and suffering of these needless deaths due to error, negligence and/or malpractice. Yet CEO’s salaries increase along with healthcare and consumer costs. Direct care workers are often the lowest paid employees in any community. Hospital CEO’s are being paid a hundred times more per year, than those people providing hands-on care to our sick, our elderly and all of us, when we are at our most vulnerable and at the neediest times in our lives. Who wants that? We must have parity! We must have social justice! We must have well staffed, well paid hospital employees! Hospitals are already the most hazardous places to be in America. We should be finding alternatives for making them safer and cost-effective for all. If hospitals are sick places and the healthcare system is broken which we all know it is-it is not sustainable, then do not cut at the hands and feet of the body of workers. Make cuts at the ‘head’, to the CEO’s salary, who has failed to provide or create, solutions. When your hospital is well staffed, you will have to pay out less in voluntary and mandatory overtime. Your employees will be well rested and of higher morale and purpose. When your employees are well paid, they will not have to work a second or third job to make ends meet. They will be higher functioning, more efficient and effective. Hospitals which are decreasing their levels of staffing should be reported to their State’s Board of Health, scrutinized, monitored and placed under investigation and/or indicted for placing at risk The Public Health and Safety, which should be our government’s number one priority job description, as Bill O’Reiley will tell you, and will be happy, I’m sure, to feature violators on his FOX News program, where he claims to be, “looking out for you.”

  9. Heather

    As a nurse I have noticed more difficulty when troubleshooting problems, asking for assistance, ordering /replacing equipment, accessing supplies or when wanting to confer with allied health staff about a patient’s rehabilitation/health on the weekend. I imagine if some issues were managed immediately instead of carried over until monday our whole system would speed up just a little. The the nurses I have discussed this with find it very frustrating to watch our patients slowing down and not benefitting from therapy programing on weekends. Our patient’s health needs don’t change on the weekend- agreed!

  10. Kira

    During the Easter Holiday I was called on Sat & told depending on bed availability I would
    be notified by 10am Easter Sunday whether to come in for a quadricep tendon repair. This was at a large major Toronto teaching hospital.

    The experience from beginning to middle to end was 1 of the worst surgery experiences I have ever had (& I’ve had more then a dozen surgeries under general anesthetic). The worst of which was insufficient pain medication resulting in a level of pain higher in post-op then when I tore the muscle. It was so bad the patient in the bed next to me was begging on my behalf. Instead I was told “this is all you’re getting so don’t even bother asking for the next 3 hours” .
    The reality was that I was given less pain medication then I take at home for other issues. [neuropathic damage, hypermobility & osteoarthritis]

    There were so many issues that following a 2 week cooling off period I sent 1 letter to the surgeon addressing issues related to him & his resident. Then I sent a second letter to the hospital about the nursing staff.

    I learned 2 lessons from this experience never have last minute semi scheduled surgery (unless it is a true emergency) & if things start to go wrong, you have every right to stop & reschedule or try & address your concerns before you hit the point of no return.

    Something has to be done & in my opinion it starts with communication, but it can’t be a one way street.

  11. Christopher Sutton

    Since we all know serious medical incidents can occur at any time, it’s good that researchers in Canada, the U.K. and elsewhere are examining this issue. The Canadian Institute for Health Information plans to release a report next spring that will examine the extent to which these patterns exist in Canada and, if so, to investigate some of the possible explanations for higher mortality among patients admitted on the weekend.

    Hopefully this report will contribute to the ongoing debate over this complex issue.

  12. Bob

    I was in the nueor ward as a quadrapalegic from a flu shot that caused guillian barre or GBS and needed the same help on weekends but did not have it.

  13. Peter G M Cox

    This seems so self-evidently obvious that I am surprised that we can afford to spend resources on research. Healthcare should be viewed like any other customer service business – that the needs of patients should drive the decision (NOT the preferences of providers) – except that, because it involves risk to patients, it is even more important than in most other customer service situations. Unfortunately for healthcare providers, patients cannot decide when to get ill, nor, once they’re hospitalized, do they need less care on Saturday and Sunday than during the week. This aspect is really a “no brainer” (and in my experience is generally accepted by other professions like accountants and lawyers when necessary to serve clients).

    The cost issue is probably, however, an impediment to early adoption of the principle. We seem to be short of doctors and, at least in hospitals, nurses; as a result there is widespread disenchantment, high stress, high absenteeism and high turnover. Given that we have in Canada one of the highest levels of per capita spending on healthcare in the World and, at the same time far fewer doctors per capita, it would appear that we are misallocating funds. Solving this problem would therefore require finding where spending provides little “value added” (in terms of patient care), formulating plans to reduce such spending and redirecting it (including training more doctors and nurses if necessary) to providing MORE “frontline” medical professionals. This, of course, would take time BUT IS NO REASON TO AVOID ADDRESSING THE ISSUE.

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