Hospital Care: Worse on Weekends?

If you could control when you got sick enough to need hospital care, it might be worth doing. According to a new study coming out in the Feb. 20 issue of the Journal of the American Medical Association, hospital care may be significantly worse on the weekends and at night than on weekdays. After reviewing the survival rates among patients across the country who experienced cardiac arrest during their hospital stays, researchers at Virginia Commonwealth University found that patient mortality rates were higher at certain times of day and on weekends, even when they factored in clinical variables like the patient's condition and what the different heart rhythms were.

"We looked at a tremendous number of patients at a comprehensive cross-section of hospitals around the country and found that survival was substantially lower at night, compared to day and evening, and on weekends regardless of what time of day it was," says Dr. Mary Ann Peberdy, who directed the study.

Peberdy and her colleagues looked at data on 86,748 adult in-hospital cardiac arrests occurring at 507 hospitals between 2000 and 2007, and found that the survival rate during weekdays and weekday evenings was 20.6 percent, while the survival rate on the weekend was only 17.4 percent and an even more disturbing 14.7 percent at night. That means patients were about 41 percent more likely to survive if they were treated during the day from Monday to Friday.

This isn't the first study to find a marked difference in hospital patients' outcomes depending on when they are treated. A smaller report on heart attack survival rates at New Jersey hospitals came out last March in the New England Journal of Medicine that indicated similar trends involving weekend care and survival rates.

Although the conclusions focused on proving correlation rather than causation, Peberdy cites short-staffing issues as a likely culprit in the lower survival rates at certain times during the week. Fewer staff members could lead to less frequent monitoring of patients and a significantly slower response time in identifying and treating a patient in distress, she says.

"When someone has a cardiac arrest, they typically begin with a rhythm you can treat with a shock. Then, if it goes unrecognized, it degenerates into rhythms that have poorer survival rates," says Peberdy. "In our study, we found that the percentage of shockable rhythms got lower at night, while the other types got higher. The fact that these rhythms switch at night and on weekends suggests that [cardiac arrests] are being found a little bit later. Surveillance decreases at night, because the staff just isn't there. And not every patient is on a monitor, so you rely on staff walking in and out of the room to find them when they've had a cardiac arrest."

Far from being isolated, these studies are backed up by years of findings by researchers who noticed similar trends in sleep deprivation and hospital staffing studies. Another article published in the Journal of the American Medical Association in September 2006 found that physicians' interns doing procedures at night were twice as likely to accidentally stab themselves with a needle or scalpel as when they were doing the same procedure during the daytime, says Dr. Charles Czeisler, a professor at Harvard Medical School and director of the school's Division of Sleep Medicine. In addition, those interns were 73 percent more likely to stab themselves if they were working a shift of 20 consecutive hours or longer.

The notorious 30-hour hospital shift has also been found responsible for an extra 36 percent of medical errors and a 460 percent rise in serious diagnostic mistakes—and even an increased likelihood that interns coming off long shifts will crash their cars on the way home. Even after taking into account possible physical causes for the differences due to circadian variations—the body's natural day-night cycle—Czeisler says the study's findings are striking. Staffing and other procedural problems are isolated as the cause because of the similarity of night trends and the daytime weekend trends. While care performance is high Monday through Friday, he says, it plummets at the same time on the weekend, when there are fewer staff members and they are generally working extended shifts.

"You wouldn't see this deterioration in performance if this were purely physiological," Czeisler says. "It's also interesting that the only area where there wasn't a significant variation between the weekday and nights or weekends is in the ER, where for more than two decades shifts have been limited to 12 hours across the country. This study reveals the importance of addressing sleep and fatigue in the hospital setting in order to improve patient outcomes and improve patient safety," he says.

Peberdy also notes that the emergency department is the only place in a hospital staffed with senior-level physicians 24/7. Often, in other areas of the hospital, the resuscitation response process is left to interns and residents, although she notes that there is no way to prove the connection with the data currently available.

Although the differences between survival rates may seem small, researchers warn against complacency when discussing hospitals' shift-scheduling and emergency-response policies. "Even small differences in mortality between weekday and weekend admissions … can translate to substantial numbers of additional deaths in the population because of the high incidence and case fatality rate associated with this condition," researchers concluded in the New Jersey study published last March in the New England Journal of Medicine. "The observation of a significant and clinically relevant increase in mortality among patients with a first myocardial infarction who were admitted on a weekend rather than a weekday—representing nine to 10 additional deaths per 1000 admissions per year—has important implications for clinical care," they wrote.

Patients who begin to notice symptoms during the week should head straight to their doctors, researchers advise. Holding out for a little weekend R&R may in fact hurt more than it helps. In addition, simply making contact with a doctor by Friday, when staff is more available, might help ensure timely weekend attention, should it be necessary. But researchers emphasize that their findings should not frighten away people experiencing serious medical symptoms at night or on the weekend.

"Survival from cardiac arrest is no worse than before," says Peberdy. "But the problem is it's no better, either. The message from this paper is to hospitals and the people who run their emergency response teams. Maybe we need to really start rethinking how we prepare for emergency response within hospitals."