Higher senior staffing levels at weekends and reduced mortality

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e67 (Published 10 January 2012)
Cite this as: BMJ 2012;344:e67

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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

Competing interests: None declared

Zaki Akhtar, F1 Orthopaedics

Radcliffe Lisk

Ashford and St Peter's NHS trust, Guildford Road, Surrey, KT16 0PZ

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As discussed in the editorial by Goddard and Lees,1 a recent report by the Dr Foster group demonstrated a higher mortality rate for patients admitted as an emergency at the weekend than for patients admitted as an emergency during the week.2 The report also suggested that hospitals with higher levels of senior staff available at the weekends were associated with lower mortality rates for emergency admissions at the weekend.2 Another recent study by Freemantle et al found patients admitted on a weekend were more likely to die in-hospital that patients admitted on a week day.3

The Society for Cardiothoracic Surgery in Great Britain and Ireland established its clinical governance and quality improvement programme for adult cardiac surgery performed in NHS hospitals in 2001.4 This programme has been associated with significant improvements in risk-adjusted mortality rates over time.5 We have used this database to investigate whether patients who undergo cardiac surgery at the weekend have an increased risk of in-hospital mortality compared to patients who have cardiac surgery during the week.

For this analysis all patients undergoing adult cardiac surgery at NHS hospitals in England and Wales between the 1st April 2008 and 31st March 2011 were included. In total 93 463 patients underwent surgery on a week day with an in-hospital mortality rate of 3.1% (95%CI 3.0% to 3.2%) and 3 234 patients underwent surgery at the weekend with an in-hospital mortality rate of 5.3% (95%CI 4.6% to 6.1%). However, emergency surgery was much more common at the weekend (689 patients, 21.3% of weekend patients) than during the week (2 446 patients, 2.6% of week day patients). On analysis of each individual day, no day of the week was associated with significantly higher risk-adjusted in-hospital mortality (Figure 1). Multiple logistic regression analysis (Table 1) demonstrated that weekend surgery was not associated with an increased risk of in-hospital mortality compared to weekday surgery after adjusting for other patient risk factors (Odds Ratio 0.93, 95%CI 0.77 to 1.12).

This analysis demonstrates that for a speciality with an established clinical governance and quality improvement programme and a primarily consultant delivered service, the risk of in-hospital mortality is the same for patients who have surgery at the weekend as it is for patients who have surgery on a weekday.

References
1. Goddard AF, Lees P. Higher senior staffing levels at weekends and reduced mortality. BMJ 2012; 344.
2. Dr Foster Health. Reducing mortality at night and weekends. www.drfosterhealth.co.uk/.
3. Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shahian D, et al. Weekend hospitalization and additional risk of death: An analysis of inpatient data. Journal of the Royal Society of Medicine 2012; 105(2): 74-84.
4. Bridgewater B. Cardiac registers: the adult cardiac surgery register. Heart 2010; 96(18): 1441-1443.
5. Bridgewater B, Keogh B, Kinsman R, P W. Sixth National Adult Cardiac Surgical Database Report. Dendrite Clinical Systems Ltd: Henley-on-Thames, 2008.

Competing interests: None declared

Stuart W Grant, Research Fellow

Graeme L Hickey, David P Taggart, James Roxburgh, Graham Cooper, Ben Bridgewater on behalf of the Society for Cardiothoracic Surgery in Great Britain and Ireland

University of Manchester, Manchester Academic Health Science Centre,Department of Cardiothoracic Surgery, University Hospital of South Manchester, Southmoor Road, Manchester, England, M23 9LT

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Like many trusts across the country, we were concerned by the reports from Dr Foster about increasing mortality at the weekends and the correlation with reduced levels of medical staffing. In our trust I routinely review the case notes of all patients who die, looking for potential learning points or systematic errors that can potentially be addressed. In response to the recent interest in weekend mortality I reviewed 53 consecutive deaths, with the specific focus of comparing weekday and weekend practice. I looked at the time from admission to junior, middle grade and consultant review. While there were cases identified across the week where time to review at all levels should have been sooner there was no difference in weekend practice compared to during the week. The point made by Dr Goddard that patients admitted at the weekend were sicker than those admitted during the week was clearly demonstrated in our patients. Twice as many patients had a modified early warning score of five or more at the weekend than did during the week. In addition, of the 53 deaths reviewed, four were elderly, frail, highly dependent patients admitted from nursing homes when they were clearly dying. In each of these four cases, on admission to hospital only palliative measures were considered appropriate. Such treatment should have been available to these patients in their own beds without subjecting them to the trauma and discomfort of an acute hospital admission simply to 'die in hospital' a few hours later. All four of the cases 'admitted to die' were at the weekend, there were no such cases during the week.

The correlation between senior medical input in hospital and weekend mortality over simplifies a complicated and multifactorial problem. It is essential that the problem of weekend mortality is considered in the context of care provided to patients both in the community as well as once they are admitted to hospital. Better provision of community out of hours services and improved end of life advanced care planning must be considered with equal weight to addressing the weekend hospital staffing and workforce configuration in hospitals.

Competing interests: None declared

colin m a wasson, associate medical director, intensive care consultant

stockport nhs foundation trust, Poplar grove, stockport, SK2 7JE

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Dr Foster Intelligence reports the observation that weekends are associated with increased mortality and low staffing levels. Goddard and Lees state that low staffing levels are only one of the factors that lead to increased mortality of patients admitted at the weekend. This advances the notion that increasing senior medical cover at weekends is not necessarily required. This failure to advocate increasing staffing levels smacks of sophistry, rather than of practicality

Patients admitted over weekends are known to be sicker than those admitted during the week – As things stand they are attended by fewer and less experienced clinicians. Surely the default response to this knowledge is to call for an immediate increase in the seniority of doctors providing acute medical care at a time that is known to have a worse outcome.

Competing interests: None declared

Malcolm John Dickson, Consultant Obstetrician & Gynaecologist

Nicola R K Anders

Royal Oldham Hospital, Oldham, Lancashire, OL1 2JH

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Dr Foster have found a univariate association between a higher relative mortality for patients whose day of admission was on a weekend with levels of "senior" medical staff. My own hospital (from Dr Foster's publically available relative risk data) also shows an association with increased mortality at weekends by age, length of stay and certain co-morbidities. It is unclear without multivariate regression analysis that senior input is an independent predictor.

That being said there will no doubt be a clamour for consultants to be on-site 24/7 as a result of this conclusion. It should be made clear however that the analysis categorised a senior doctor as ST3 or above. ST3 is the most junior grade of registrar and traditionally only consultants or associate specialists are regarded as senior. As such any rearrangements of cover that may stem from this analysis should concentrate on increasing ST3+ members of staff (an acute illness rota) rather than concentrate on consultants alone.

Consultants drafted in at weekends are often, in my experience as a physician, asked to see perfectly well patients to decide upon their fitness to be discharged or outlaid onto non-medical wards or to perform the unfocussed "Post Take Ward Round" rather than see genuinely critically ill patients to whom a senior decision may be the difference between life and death as Dr Foster's report intimates.

If consultants are to be required to be present in hospital outside of traditional working hours, in increased numbers, then please allow us to see the genuinely sick patients (and hence to teach the junior medical staff) and not be there just to tick boxes about meeting "seen by a consultant within x hours" targets.

Competing interests: None declared

Richard Ian Shepherd, Consultant in Acute Medicine

Mid-Yorkshire NHS Trust, Pinderfields Hospital Wakefield

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We welcome Goddard and Lees timely editorial and its recognition of the importance of the Registrar role [1]. The authors highlight that the Dr Foster Hospital Guide [2] did not report any association between the numbers of junior doctors (ST2 and below) and the differences seen in weekend mortality rates. Given the high volume of clinical care delivered by junior doctors on weekends we find Dr Foster’s result surprising, and are not alone in this [3].

Although Dr Foster Intelligence notes that “junior doctors work around the clock” the overall numbers available out of hours tend to be much smaller than during the weekday. With Hospital at Night and the rota systems implemented under the EU Working Time Directive, this smaller cohort of junior doctors is often looking after patients that they have never met before, whilst cross-covering specialities they are unfamiliar with.

Although senior input is often available, this is similarly stretched with higher ST grades being burdened with clerking new admissions and patient reviews. Furthermore, in an ageing population with a high prevalence of co-morbidities, the patients occupying hospital beds are more complex than ever. To digest weighty volumes of notes in the short period that an on-call doctor can spend with a patient is increasingly difficult, compounded by night nursing staff that are often unfamiliar with the patient’s pre-morbid state.

Whilst increasing the numbers of ST3+ doctors available out of hours is clearly important [4], it is only one piece of a complex healthcare puzzle. The number of junior doctors needed out of hours for the delivery of quality care, and to meet training needs, should be further investigated. Medical needs, rapid deterioration in patient status, and acute emergencies do not obey the 9–5 working week - nor should a medical system that prides itself on equity of access to care.

[1] Goddard A, Lees P. Higher senior staffing levels at weekends and reduced mortality. BMJ 2012;344:e67.

[2] Dr Foster Health. Reducing mortality at nights and weekends. In: Inside your hospital 2011. http://drfosterintelligence.co.uk/wp-content/uploads/2011/11/Hospital_Gu... (accessed 12 Jan 2012)

[3] Macdonald H. Dangerous weekends - more complicated than just a lack of consultants. BMJ Group Blogs 2011. http://blogs.bmj.com/bmj/2011/11/29/helen-macdonald-dangerous-weekends-m... (accessed 12 Jan 2012)

[4] RCP Council. RCP position statement on the care of medical patients out of hours. Royal College of Physicians 2010. http://old.rcplondon.ac.uk/professional-Issues/Pages/RCP-on-care-of-medi... (accessed 12 Jan 2012)

Competing interests: Competing interests: ZA, VK, CJR and ANT are junior doctors as defined by the report. All authors are fellows in the NHS Medical Director Clinical Fellows Scheme hosted by the Faculty of Medical Leadership and Management.

Grant A Hill-Cawthorne, ST3 in Medical Virology

Zeinab Abdi, Academic F2, Leicester University Hospitals; Eamonn Breslin, ST6 in O&G, North London Rotation; Colin Brown, Academic Clinical Fellow in Infectious Diseases & Microbiology, King’s College London; Nick Ibery, Neurosurgery, North London Rotation; Varo Kirthi, Academic FY2, The Royal Marsden NHS Foundation Trust; Anna Moore, CT3 Psychiatry, Berkshire NHS Foundation Trust; Carl J Reynolds, CT1, Chelsea and Westminster Hospital; Aniket N Tavare, CT1, Oxford University Hospitals NHS Trust; Wai Keong Wong, ST5 in Haematology, North Central London Rotation

Norfolk and Norwich University Hospitals NHS Foundation Trust, Specialist Virology Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY

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