Re: Higher senior staffing levels at weekends and reduced mortality
Recent emerging evidence (1) has suggested that patients admitted during the weekend have a higher mortality than those admitted during the week. This is thought to be strongly associated with the lack of cover of senior doctors (registrar or consultant level), during the weekends (1, 2). But how true is this for patients admitted with a hip fracture in a district hospital?
We attempted to answer this question by evaluating the mortality rate for patients with hip fracture who were admitted on a weekend, compared to the ones admitted during the week. A total of 1039 hip fractures admitted from April 2009 to January 2012 patients were included in this analysis.
Overall, week day admissions had a mortality rate of 7.0% whereas weekend admissions had a mortality rate of 5.2% (statistically no difference, OR = 0.722, LCL= 0.39). Of these days, interestingly, Wednesday had the highest mortality rate (9.2%) and Saturday had the least (4.2%). This could partly be explained by the higher number of hip fracture admissions on Wednesdays (174, 16.75%) compared to other days and more significantly, by a lack of experienced trauma surgeon available on Wednesdays compared to the other days.
Dr Goddard also pointed out that patients admitted over the weekend tend to be sicker, owing to the variation in referral practice. Our analysis found that an equal proportion of patients in each ASA grade (marker of fitness for surgery) were admitted during the weekdays as were admitted over the weekend. This suggests that patients with a hip fracture admitted over the weekend were no sicker than those admitted over the week. Hip fractures, in most cases, are sustained through a traumatic event such as a fall. Such traumatic events commonly lead to emergency referrals, irrespective of the day of the week and hence there is no obvious “wait” for a referral. Thus there is no variation in the sickness level of patients admitted over weekends or weekdays.
Further analysis demonstrated that since regular weekday orthogeriatric input from May 2010(daily consultant assessment pre-operatively during the week) for hip fractures, there was no difference in mortality rates of hip fractures admitted over weekends (4.5%) compared to weekdays (6.5%). However, overall mortality has fallen since this practice became compulsory (7.38% to 5.96%).
Dr Foster’s report exposes an alarming shortage in the healthcare service provided throughout England. However our analysis suggests that perhaps the Dr Foster’s intelligence findings may not be applicable to the patient’s with hip fractures. Despite having more consultant cover during the week, there is a statistically similar rate of mortality in hip fracture patients admitted over the weekend and week days. As Dr Goddard rightly expressed, more work is required in identifying what specialties require an increase in doctors.
1. Dr. Foster (The UK leading health information company) 10th edition www.drfosterhealth.co.uk
2. Goddard et al; Higher senior staffing levels at weekends and reduced mortality; BMJ2012;344:e67