May 23rd, 2011
Suppose you need to drive from Boston to San Francisco, about 3200 miles, over the next 7 days. At an average speed limit of 55 mph you could accomplish this by driving about 10 hours a day, including stops for rest and food breaks; a grueling but not impossible journey.
Now suppose that gas stations are closed on weekends. With your driving limited to 5 days, you would be forced to drive above the speed limit or drive a longer day, either of which decreases safety. In addition, since you are not the only one affected by weekend gas unavailability, the volume of traffic you encounter would be higher, and even a small accident or increase in congestion would produce a slowdown or even gridlock with further waste of time and gasoline. In summary, in the second scenario you have lower safety, lower efficiency and higher cost.
This example is exactly what happens at most hospitals. Hospitals choose to slow down on patient care activities on weekends. No doubt there are important social reasons why hospitals operate differently on weekends than on weekdays. Important as these reasons may be for hospital workers and care providers, it is equally important to fully understand the implications for patient care, the raison d’être for every hospital.
The result of a weekend slowdown at hospitals is that more patients have to be pushed through during weekdays. The effect of doing so is similar to driving faster than the speed limit. This weekday push significantly decreases safety and increases healthcare cost. In light of untenable costs, growing demand from an aging and newly insured population, and quality of care that is not commensurate with the highest healthcare costs in the world, we can no longer ignore the cost and quality repercussions of hospitals working five days a week.
The Current Model And Its Ramifications
Let us take a closer look at the how and why of the current hospital operating model and its implications. Ideally hospitals would prefer to shut down on weekends altogether in order to afford all staff a regular work week. It is not possible to do so for two reasons. First, some patients’ clinical needs arise on weekends and these constitute a hospital’s urgent and emergent weekend admissions. The second reason is that a number of the patients who are admitted during the week require hospital care for more than one day, and some of those patients necessarily have to be cared for during weekends.
Not much can be done about the first set of patients, so hospitals have to provide at least some resources to care for them. The second set of patients needs to be considered in two distinct groups: 1) patients who are admitted during the regular week on an urgent or emergent basis, and 2) patients who are admitted electively. Again, while the timing of urgent and emergent admissions more or less has to be accommodated, elective patients are often scheduled to be admitted to a hospital several weeks in advance. Since the goal is to minimize weekend occupancy, elective patients necessarily have to be admitted earlier in the week in an attempt to discharge most of them before the weekend. In effect, hospitals operate in overdrive mode during weekdays with several attendant negative effects.
A Typical Week At The Hospital
Hospitals start most weeks with a low occupancy but quickly get to gridlock by early to mid-week, driven by elective scheduled admissions. This bunching of scheduled admissions has now been shown to severely affect the ability of nursing and other staff to provide quality care. A recent study showed that patient exposure to understaffed nursing units and increased patient turnover (admission, discharge and transfer) activity each have a statistically significant effect of increased hospital inpatient mortality. Another study established a link between the risk of readmission and a peak in admissions to an ICU.
In addition to increased mortality and readmission risk, mid-week gridlock imposes significant delays for new admissions to the hospital manifested as emergency department (ED) diversion, ED and Post-Anesthesia Care Unit boarding, and placement of patients in inappropriate care locations. To compensate for patient placement issues hospitals resort to specialized care provider teams that are deployed when patients deteriorate because of inadequate care. Medically appropriate transfers from other institutions may also be delayed or rejected.
Patients who are in the hospital over the weekend fare even worse. Patients who are admitted over the weekend have an increased risk of morbidity and mortality because critical diagnostic or therapeutic modalities are not available. Existing inpatients also experience weekend delays at best, and deterioration in clinical condition at worst, for the same reasons. Chemotherapeutic protocols may be interrupted, post-surgical rehabilitation prolonged, and medical diagnosis delayed because key physicians or services are not available.
It is increasingly well appreciated that hospital quality of care on weekends is compromised; it is less widely appreciated that restricting services over weekends also reduces the ability of hospitals to deliver quality care during the regular five weekdays. In addition to the significant quality ramifications, another result of this weekly pattern of feast and famine is that US hospitals are only about 66 percent occupied on average. If we continue current practices we will need to spend billions of dollars that we don’t have on building additional hospital capacity to accommodate the growing demands of an aging and newly insured population.
A Better Way Forward
The alternative is to move toward 7-day hospitals. While a 7-day operation will require some significant changes in workflow and staffing, it can also lead to a more predictable work-life balance with decreased stress for all hospital workers. If we wish to achieve anything more than marginal improvements in cost and quality, health care professionals have no choice but to carefully consider whether weekends off are more important to us than the quality and cost of care we provide to our patients.Email This Post Print This Post
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