Recently, while working a morning emergency shift in a major Toronto hospital, I realized how rare it is that I actually work in a hospital that functions at full capacity. I should be more clear—I’m not talking about patient capacity. Functioning at over-capacity is the norm in that regard. I’m talking about clinical, diagnostic, interventional, administrative, and pretty much anyone-who-is-not-a-patient capacity.
It’s not like this is news to anyone who works in hospitals, but most of us just get used to it. Sending people home at midnight to return for an ultrasound at 8 a.m. the next day for a potentially serious condition is something we do several times each night. What’s the alternative? The ultrasound tech is at home. We would also need to convince the radiologist, who needs to interpret the scan, that the interpretation cannot wait until the morning, which it usually can. And so it usually does.
But sometimes patients are so frail, or in so much pain, that it becomes unsafe to send them home at midnight. Thus they wait in the emergency department. And because the ED has used up its beds, chairs, and other uncomfortable surfaces, patients wait in hallways and in the waiting room.
Slowly, factors start to accumulate which contribute to an unsafe environment. Similar issues occur throughout the rest of the hospital in much of the province, such as with patients who cannot be discharged from a ward on weekends because the nursing homes or rehabilitation facilities or supportive housing they came from will not accept them.
So, what’s the alternative? Having the same number of people working overnight, on weekends, on holidays? Well yes, that would likely solve some of the problems. So why does it not happen? Presumably because that would be quite expensive, but also because we can get away with less, at least most of the time.
I once responded to a Code Stroke at 3 a.m. I was the junior resident on call in a rotation I had just started, in a hospital I had never worked in. The patient showed up to the ED without any heads up from EMS. My senior team members had just been alerted and were making their way to the hospital. While examining the patient, who could not communicate due to his new speech deficit, I was trying to find a clerk to register the patient into the hospital system. Without this, I could not enter the necessary orders for his CT scans. Unfortunately, there was only one clerk working overnight and he was nowhere to be found, possibly on a break. Meanwhile, the CT scanner in the ED was down and there were no porters immediately available to transport the patient to the other scanner on a different floor, since they were also short-staffed. To save time, the only available nurse and I decided to go ahead without a porter, while carrying all the necessary equipment and continuing our assessment of the patient. During the transport, the intervention team kept calling to ask what the CT scan showed, so they could prepare appropriately. Then the patient’s family arrived, clearly in a panic. There were no extra personnel available to speak with them, so the nurse and I took turns. Trying to find out the patient’s medical history, asking his family about his wishes, informing them of his diagnosis, and getting consent for possible interventions was not easy to do while rolling down a hallway with a cellphone in one ear and several pieces of equipment in my hands.
Somehow, this patient ended up getting what he needed in reasonable time. But that night, the system seemed ripe with opportunities for error and failure, especially for a condition where “time is brain.” The fact that a depleted health care roster was able to deliver prompt and effective care was not because of the system we found ourselves in, but in spite of it. This happens in Ontario, and in many other places, on a nightly basis, as well as on weekends and holidays. While the training, adaptability, and resilience of our health care providers should be recognized, this type of environment should not be encouraged, nor allowed.
“It should surprise no one that a system that provides a full solution five days a week cannot match a problem that occurs seven days a week,” says Peter Viccellio, professor at Stony Brook School of Medicine, New York, and renowned lecturer on the topic of hospital boarding and over-crowding.
According to Viccellio, the nine-to-five system initially worked quite well because, when it came about in the 1960s, most hospital admissions were for predictable, elective procedures and simple medical conditions. Having a skeleton crew on evening and weekends made sense. However, we now get many more unscheduled admissions through the ED and these are not limited to daytime or weekdays. Additionally, the patients are older and much more medically complex, requiring more investigations, more procedures, and longer stays. Yet our hospitals continue to be understaffed on nights, weekends, and holidays.
What’s even more disappointing is that we have known about “the weekend effect” for many years. Studies have shown that weekend admissions are associated with significantly higher mortality rates for many of the leading causes of death. The same has been found for off-hours admissions, including holidays. Although we are still unclear about the true causes of these phenomena, reduced staffing and supervision, increased workloads, and limited resources must surely be playing a role.
I sometimes wonder if patients know about these differences in staffing and resources, or about such things as “the weekend effect.” Perhaps they’ve suspected that the hospital is not functioning at full capacity after 5 p.m. or on weekends, but I wonder if they feel more at risk when they come in during these times. I also wonder if they overhear staff whispering phrases like “just survive until the morning” to each other. I wonder what this makes them think of us?
Sadly, as far back as 2013, researchers from Ontario wrote: “Whether reduced weekend capacity is the result of cost-saving strategies or hospital staffing preference, it is clearly problematic. Unfortunately, evidence of harm… is often the only way to force a culture change. At this point, the evidence seems sufficient to justify a change in how we deliver care at weekends.”
There are definitely no simple solutions here and a discussion of potential changes merits nuanced discussion with feedback from many parties. However, I think one thing is clear: Hospitals are not banks and they should stop working banker’s hours.