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Just Another Hospital Weekend, Or Life And Death?

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.

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6 Trackbacks for “Just Another Hospital Weekend, Or Life And Death?”

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  3. View:nHospital weekend staffing practices dangerous, costly | Seattle/LocalHealthGuide
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5 Responses to “Just Another Hospital Weekend, Or Life And Death?”

  1. kamerick Says:

    Speaking as one agonizing from afar while my sister sends updates right now on my mother – on a Saturday – who is getting almost no care, this resonates very personally for me. She has had to threaten litigation to get someone to run tests on her and consider moving her to the ICU because she can’t breathe. I’m sorry – but this sounds like I’m some third world hell hole. What the hell?? I wish you could get this message out to every hospital in nation.

  2. Sandeep Green Vaswani Says:

    The goal of our blog entry was to put the spotlight on an ill-recognized albeit crucial link between 5-day hospital operations and patient safety, quality and healthcare cost. Like with any improvement idea, this one can benefit from governmental and private payer incentives as Mr. Millenson indicates. That said, we do believe, based on our experience working with numerous hospitals, that the key hurdle is lack of understanding and not provider malfeasance. If it were the latter, we would have a much bigger problem in healthcare than the willingness of providers to work seven days a week. Indeed, a detailed road map to move hospitals from 5 to 7 day operations needs to be developed, and we encourage experts in the field to contribute their expertise and perspectives. We thank Mr. Millenson for further spreading the word on this important issue.

  3. fieldston Says:

    A timely piece of work related to this issue for children’s hospitals….

    Researchers offer admissions strategies to reduce hospital overcrowding May 19, 2011 | Richard Pizzi, Editor

    PHILADELPHIA – Too many admissions at a hospital at one time can put patients at risk, but a new study suggests that “controlled entry” of patients can reduce variations in occupancy rates and boost patient safety.

    Researchers at the Children’s Hospital of Philadelphia discovered that “smoothing” occupancy over the course of a week could help hospitals reduce crowding and protect patients from crowded conditions. The strategy involves controlling the entry of patients, when possible, to achieve more even levels of occupancy instead of the peaks and troughs that are commonly encountered.

    The study, published in the Journal of Hospital Medicine, analyzed inpatient information from 39 children’s hospitals during 2007 and used it to compare weekday vs. weekend occupancy and to model the impact that smoothing inpatient occupancy has on reducing variations in occupancy.

    Lead researcher Evan S. Fieldston, MD, said it was obvious that smoothing over the whole week would reduce peaks and raise troughs to average levels, but his team sought to quantify just how large these differences are – and thereby quantify the potential of smoothing to reduce inpatient crowding. If smoothing does not significantly reduce crowding, then other strategies might be of more value.

    The analysis revealed that weekday occupancy exceeded weekend occupancy – hospitals’ average occupancy ranged from 70.9 percent to 108.1 percent on weekdays and 65.7 percent to 94.9 percent on weekends. After smoothing, each week’s maximum occupancy within the hospitals was reduced by an average of 6.6 percentage points. Through smoothing, 39,607 patients from the 39 hospitals were removed from settings where occupancy levels exceeded 95 percent. To achieve within-week smoothing, a median of only 2.6 percent of admissions would have to be scheduled on a different day of the week; this equates to a median of 7.4 patients per week.

    “Scheduled admissions contribute significantly to variability in occupancy at hospitals and raise the risk of mid-week crowding,” said Fieldston. “Predictable patterns of admissions lead to high occupancy on some days and unused capacity on others, which can be addressed with proactive management of admissions.”

    He suggested that by smoothing out variation and spacing scheduled admissions over the week, hospitals can reduce crowding without delaying admissions or investing in expensive new beds. Also, patients who are admitted on weekends experience more delays in treatment and have worse outcomes, so increasing the capability of hospitals to function more fully seven days a week would make the system better and safer.

  4. John Ballard Says:

    Improved service. What a concept!

  5. Michael Millenson Says:

    This is a wonderful article that should be slipped under the office door of every Congressman in America and maybe even those of a few editorial writers for major newspapers. Unless, of course, the authors believe that the readability of their prose, the logic of their argument and the strength of their footnotes will cause members of every hospital board of directors in the nation (and, likely, worldwide) to rise up, slap their foreheads while declaiming, “What fools we’ve been!” and change their entire institution. If not, it would be nice to have a suggestion or two about ways policymakers and private payers might encourage this logic to translate into action, Alas, a hospital administrator suggesting a seven-day-a-week schedule to his medical staff might find himself looking for a new job with the authors’ think tank.

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