Weekend Effect Persists

Recent research published in the Journal of the American Medical Association (JAMA) highlights a continued hospital care issue identified in previous studies: worse patient outcomes from in-hospital cardiac arrests occur at night or on the weekend.1

An analysis of 86,748 adult cardiac events between January 2000 and February 2007 in 507 hospitals participating in the National Registry of Cardiopulmonary Resuscitation (NRCPR) compared outcomes at night (from 11 p.m. to 6:59 a.m.) and weekends (from 11 p.m. Friday to 6:59 a.m. Monday) with day/evening shifts. The primary measure of survival to discharge and secondary outcomes from in-hospital cardiac arrests were significantly worse during nights and weekends. In essence, heart attack patients were 41% more likely to survive if treated during daytime weekday hours.

“This was the first comprehensive, large-scale study in a cross section of hospitals across the country of heart attack survival differences between shifts,” says lead author Mary Ann Peberdy, MD, of Virginia Commonwealth University in Richmond. “We adjusted for a variety of potentially confounding factors and patient characteristics, none of which explained the worse outcomes nights and weekends.”

The national database was not designed to provide an explanation for its findings, which may be due to multiple patient, event or hospital factors. “We can’t exclude physiological factors of patients or of staff working on the night shift,” Dr. Peberdy explains. “But I think we need to focus on process issues. We know that hospitals simply do not run the same way at night. Things are different—more errors, more accidents, more needle sticks, less people around. Those who work the night shift may also be less experienced,” and early identification of heart attacks is critical to positive outcome.

The JAMA results confirm previous research documenting worse outcomes on nights and weekends. Single-site studies and a smaller study of heart attack survival in New Jersey hospitals for weekend versus weekday admissions found similar trends.2

Stroke patients who enter the hospital at night or over the weekend are more likely to die in the hospital than those admitted during daytime hours (7 a.m. to 6 p.m.) on weekdays, according to two studies presented at the American Heart Association’s International Stroke Conference in New Orleans in February 2008.3 Those differences were particularly striking for hemorrhagic strokes. Similar outcomes also have been reported for pulmonary embolisms.

Off-Hours Problems

Hospitalists are able to pick up on problems and patterns that may influence quality trends after hours. They also are involved in hospital committees, quality initiatives and conversations with administrators—forums in which identified problems can be addressed. Other suggestions for how hospitalists can address the shift differential for quality include the following:

Pay attention. First identify where the problems are, says David Grace, MD, Southwest Medical Center, Lafayette, La. “The problems we identify are because of repetition, which a primary care physician visiting the hospital might not notice.” Identify particular resources that could make a big difference, for example, interventional radiology.
Work proactively with the hospital’s administration and with medical specialists. A dialogue with specialists could clarify why the specialist on-call needs to be accessible to the hospitalist working the night shift and what kinds of questions the hospitalist should be able to answer on their own—with additional in-service training provided by the specialist.
If specialists are not responsive, push back—and, if necessary, take it to a higher level. “You can stabilize the patient but you can’t fix certain things—you’re not the specialist,” says Steven Liu, MD, Emory Eastside Hospital, Atlanta, Ga. It may be necessary to document in the charting note that the specialist was asked to come in but refused, and then revisit the conflict the next business day. In rare cases, it may even be necessary to go to the specialist’s department head or the hospital’s administration, which has a natural interest in optimizing patient care and avoiding actionable medical crises, Dr. Liu says.
Get additional training. Based on actual problems and identified knowledge gaps, the hospitalist group or a few of its key members may decide to seek education and certification in, for example, stroke care, critical care, or the American Hospital Association’s Advanced Cardiac Life Support course (www.acls.net).
Participate in designing and helping to staff rapid response teams or similar hospitalwide programs for responding to crisis cases. It all comes down to staffing, says Jeffrey Robinson, MD, Intermountain Medical Center, Salt Lake City, Utah. “Any time you can get an attending physician in the house, like a night shift hospitalist, you’ll impact these outcomes.”—LB