Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2424 (Published 28 May 2013) Cite this as: BMJ 2013;346:f2424
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Dear Editor,
The debate surrounding the seven day working week seems to focus on increasing consultant presence in hospitals 'out of hours'.
Looking at the system from the bottom up, it surprises me that the number of junior doctors on the shop floor has not come under similar scrutiny.
Aylin et al, identified two particular trends in mortality, an increase from Monday to Friday and a large jump at the weekends1. Could the rise in mortality through the week, found by be simply due to an increasing number of patients who have undergone surgery accruing from Monday to Thursday stressing the system?
The biggest increase in mortality in those operated on over Friday through to Sunday may perhaps be due to the seemingly ubiquitous practice of drastically reducing the number of doctors, in particular junior doctors, working out of hours and at weekends. A single foundation year 1 (FY1) doctor may cover a number of wards, as many as 60-100 patients. Their immediate senior, the SHO may cover twice that number or more, and so on up the ladder.
An overloaded FY1 may be the reason that worrying blood results are not seen until the late hours of the day, or that fluids, antibiotics and medications are not prescribed on time. Reduced numbers of juniors introduces a delay in the initial review of an ailing patient and in passing them up the chain, long before a consultant brings their expertise to bear.
Extra out of hours consultant presence may well be needed to improve patient care. At present, not every patient will see a consultant on these days. We feel it fair to say that these two days of the week, along with the similarly staffed public holidays, are regarded by all grades as the most stressful.
That being said, in our experience as a Foundation doctors, senior advice at the weekend is not as difficult to obtain as getting to your patients to perform the basics in a timely manner once (predictably) someone gets sick. As for getting a job done without a bleep interrupting...
The idea that the wards at weekends are staffed with inexperienced, incompetent juniors is incorrect. They are simply understaffed with overstretched junior doctors.
Yours sincerely,
Dr. Alistair Macey
Foundation Year 2 Doctor
Glasgow Royal Infirmary
Dr. Sean Martin
Foundation Year 2 Doctor
Glasgow Royal Infirmary
References
1. Aylin P ,Alexandrescu R ,Jen MH ,Mayer EK ,Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ 2013;346:f2424
Competing interests: No competing interests
Does any one else find it curious that mortality rates rise in a smooth manner as one moves from Monday through the week? Mortality rates compared to Monday are 7% higher on Tuesday, 15% higher on Wednesday, 21% higher on Thursday, 44% higher on Friday and 82% higher on the weekend.
If the cause is poor care in the first 48 hours why is mortality 15% higher on Wednesday?
This looks to me like some type of basic systemic error perhaps involving the routinely collected data. Maybe the problem is with the coders not the junior doctors.
Competing interests: No competing interests
Dear Editor
After feeling the full force of the media tidal wave in response to the publication of Aylin et al's excellent analysis. I read this article carefully in an attempt to find some meaningful reasons why there would be such a difference between Monday and weekend 30 day mortality for patients undergoing elective surgery. The media suggests that hospitals are grossly understaffed due to work shy Consultants not wanting to work weekends. Leading to junior staff being left to run amok killing patients left right and centre.
Despite this impression, my own observations (having been qualified for 10 years) lead me to believe that elective surgery undertaken on a weekend tended to be waiting list initiative procedures. These lists are typically undertaken by Consultant Surgeons who work for the trust (not middle grade doctors or locum consultants from out of town).
I thought perhaps the weekend cohort of patients may be sicker but this assumption was quashed on reading "Of note, weekend patients tended to have less comorbidity, fewer admissions, longer waiting time (on average seven days more), and lower risk surgery than the Monday patients." This would also fit with the typical case profile selected for a weekend waiting list initiative.
So if it not the patients, the operators or the complexity of cases then it must be due to the fact that hospitals on the weekends are set up to deal with emergencies only. Increasing this burden on already tight resources with elective cases means that any immediate complications may not be able to be recognised or managed appropriately in comparison with the weekdays. This increases morbidity and mortality.
My fear is that evidence like this may be used as a driver to perpetuate the myth that 7 day working for Consultants is the answer. The truth in my eyes is that Consultants don't work in isolation and if we are truly going to make seven day working effective then we have to make sure all members of the workforce that are required to run a hospital are around. This includes junior doctors, nursing staff, administrative staff, secretaries, porters, occupational and physiotherapists, pharmacists, laboratory staff, cleaners, canteen staff, drivers etc (please accept my apologies for anyone I may have missed).
In the current time of austerity this is obviously not feasible and perhaps we should accept that weekends in hospitals are for emergencies only and make sure we do the best for this cohort of unwell patients.
Elective work should be during week when the expertise is around to manage the post-operative care appropriately.
Dr Ajay M Verma
ajaymarkverma@gmail.com
Competing interests: No competing interests
Dear Sir
We read with interest the paper by Aylin et al entitled “Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics” [1].
Their conclusions suggest “a higher risk of death for patients who have elective surgical procedures carried out later in the working week and at the weekend.”
From the results presented it is easy to see how they have reached this conclusion however the interpretation of their results and its implications requires further consideration. In the methodology section they describe collapsing “Saturday and Sunday into one category”. This is an incorrect assumption. In many hospital trusts there are waiting lists initiatives routinely being performed most Saturdays (especially in high volume specialties such as Orthopaedics). Essentially in terms of elective productivity there is often little difference between a Friday and a Saturday. This is in contrast to Sunday, which seems to have on the whole remained a day of rest for the NHS, certainly in terms of elective surgery. This in turn has implications in the interpretation of their results.
Another important point to consider is that consultants undertaking higher risk elective surgery may opt for a Friday operating slot to allow their patients to have a longer stay in a high dependency unit than perhaps if this surgery was performed on a Monday, as the demands of these units are marginally less on the weekends as there is less elective surgery.
The main point though missed by the article is how this impacts on the push towards a 7 day a week elective service [2,3]. The concern here is that studies such as this are pushed to highlight the “inadequacies” of junior doctors managing the wards. The reality however is that if the NHS does adopt a 7 day working week with regular elective procedures over the weekend this will produce extreme pressures on a system already being seen to fail. When consultants are asked to do additional elective surgery on the weekends it places extra strain on all the other aspects of patients hospital care often to the their detriment. This includes extra patients and demands for nurses on the ward, for post-operative physio (absolutely vital for elective Orthopaedic patients), for the lone on-call SHO to manage (who is already fire fighting the ward and admission issues) and less capacity for admission from accident and emergency (an increasingly difficult issue to manage in the current era of emergency centre downgrades). Clearly to make a 7 day a week NHS work safely serious additional funding and recruitment would be required, a problem only exacerbated by the constraint on working hours by EWTD. In these financially austere times any extra substantial investment seems unlikely as the NHS faces the reality of real budget cuts.
This study does present important evidence. However we must be careful in its interpretation especially if the march to a 7 day working week continues unabated in combination with a lack of appropriate funding for all levels of doctors, nurses, physios and radiographers. If we all simply continue down this road without careful forethought we face the inevitability of further erosion of standards of care, patient management errors and a real increase in mortality rates.
Yours sincerely,
Toby Colegate-Stone
MA, MBBS, MRCS (Eng), MSc, FRCS (Tr & Orth)
SpR Orthopaedics South East Thames Rotation
Darent Valley Hospital, Dartford
Mr S Sait
LLM, MSc, FRCS (Orth)
Consultant Ortopaedic Surgeon
Darent Valley Hospital, Dartford
References
1. Aylin P ,Alexandrescu R ,Jen MH ,Mayer EK ,Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ 2013;346:f2424
2. Seven day Services- NHS Improvements http://www.improvement.nhs.uk/documents/SevenDayWorking.pdf
3. Everyone counts: Planning for Patients 2013/2014. NHS England. http://www.england.nhs.uk/wp-content/uploads/2012/12/everyonecounts-plan...
Competing interests: No competing interests
Sir/Ma'am,
I read with interest the article by Aylin [1] describing their observations of worse elective surgical outcome with the ‘weekend effect’.
I have been spurred by the view from the eyes of Peter Thomson, a junior doctor who has voiced his concern that junior doctors are unfairly being tarred by various aspects of the media [2].
I would like to support his concerns that to allow junior doctors, as a cohort, to be blamed for the effect of the NHS system only serves to lower morale and lower the retention of a key workforce [3] under strain from increasing workload [4]. It has been known since at least 2007 that junior doctors are feeling the negative effects of the EWTD [5]. Do we want to see how much more straw we can throw on before we break the camel’s back?
As a proposed response, maybe we as an organisation should be pro-active and improve our workforce planning by employing larger on-call teams, i.e. 1x SpR, 2x Core Trainees and 1 Foundation Doctor. This allows them to be able to simultaneously anticipate the unrelenting flow of referrals and appropriately resource the on-call team to deal with sick patients. Everyone can actually care for patients rather than trying to hold off the tide. The SpR can operate and have SHO assistance to call on if required, the 2 SHOs can be managing the take, referrals and supervising the wards with redundancy to manage the sick surgical patient, and the Foundation doctor be the firm foot on the ground ensuring the wards are running smoothly and be the first port of call for nursing staff. By having enough personnel who can effective manage acutely sick patients we can try and mitigate this weekend effect.
We may even change the junior doctors view of being just service delivery [6], patient outcomes may improve and we all would enjoy our work again by all having opportunities to learn from our seniors and teach our juniors.
But, taking off my rose-tinted spectacles, there is the unanswered question of where we get the Core Trainee given difficulties juggling the rota [7] . . . . . back from Australia?
1. Aylin P ,Alexandrescu R ,Jen MH ,Mayer EK ,Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ 2013;346:f2424
2. Re: Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics http://www.bmj.com/content/346/bmj.f2424/rr/648004
3. http://www.telegraph.co.uk/comment/personal-view/3638338/Were-training-doctors-for-Australia.html
4. Workload is rising and morale is falling among UK doctors, BMA survey shows. BMJ Careers 16 Oct 2012. http://careers.bmj.com/careers/advice/view-article.html?id=20009283
5. Ahmed-Little Y. Implications of shift work for junior doctors. BMJ. 2007;334(7597)777-778.
6. Scallon S. Education and theworking patterns of junior doctors in the UK: a review of the literature. Medical Education. 2003;37(10):907-912.
7. Fitzgerald JE, Caesar BC. The European Working Time Directive: a practical review for surgical trainees. Int J Surg. 2012;10(8):399-403.
5.
Competing interests: I am a junior doctor and still intend to apply for Core Surgical Training in the UK.
We read with interest, Dr Aylin and his colleagues’ thought provoking paper [1], which attracted a very significant amount of media coverage. There are various factors that contribute to outcome of surgery. The patient and their co-morbidities, the surgery and its inherent risks, the anaesthetist, the postoperative care and last but not least the surgeon and his/her experience and skills. The authors have adjusted the data for the first two of the above factors and suggested that the difference observed may be due to the quality of care the patients receive in the acute post operative phase at the weekends.
We believe that the potential variability in surgeon’s experience and its role in determining the outcome of the surgery has been overlooked in this study. This can be the source of potentially significant bias.
Friday operating lists are less desirable amongst Consultants for undertaking major surgery. One reason is that the conscientious surgeon prefers to personally see their patients on the day after surgery, whenever possible. Most surgeons that undertake complex surgery would like to be contacted personally in case of any complications arising postoperatively, whether or not they are on-call. It is therefore conceivable that over time, some more senior Consultants may try to hand over their Friday operating lists to new appointees, who invariably have less experience. This would mean that the experience of Consultants may not be equally distributed over weekdays. We do not claim that this practice is widespread or even common and have no evidence to support it; In fact, we are an example to the contrary. JW maintained his Friday operating list until he retired and handed the list over to SK, his successor.
The relationship between postoperative mortality and the seniority of the Consultant surgeon is yet to be established but there is some evidence to suggest that the learning curve for complex surgery continues even after long periods of training [2].
We put to the authors that in the absence of adjustment for this important variable, the weight that is attributed to the weekend postoperative care as a potential cause for the observed effect should be regarded with caution.
1. Aylin P ,Alexandrescu R ,Jen MH ,Mayer EK ,Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ 2013;346:f2424
2. Hardacre J. Is there a Learning Curve for Pancreaticoduodenectomy after Fellowship Training? HPB Surg. 2010; 2010: 230287
Competing interests: No competing interests
Sir
This article and its findings are probably of relevance and interest to the majority of clinicians working in public sector hospitals in the UK and elsewhere.
The primary observations may not come as a surprise to most people; but the underlying reason(s) cannot necessarily be derived from application of the Occam's principle - i.e. the most appealing and simple explanation that poor postoperative care at the weekend is the cause.
Although the authors have accounted for several possible confounding effects on mortality and have shown that the 'weekday' and 'weekend' effects persist despite patients operated at the end of the week having lower risk profiles, there are certain hidden 'effect modifiers' that could have influenced the observed effect. Some of these are the following...
1. It is well known (at least in the NHS), that Friday lists are often allocated to junior or recently joined surgeons - the lower experience potentially influencing the mortality rates on these days.
2. Patients whose operations are cancelled are often accommodated in the next few days of the week. This could mean that there are more patients being operated later in the week that have waited for a few days in hospital. This extra 'pre-operative hospital stay' associated with reduced mobility, intravenous infusions and longer periods of 'nil by mouth' may have an influence of postoperative mortality.
3. It could also be that staff involved in complex high risk interventions get increasingly tired as the week goes by and could be a potential factor that explains increased mortality later in the week!
Even assuming that the observed effects are true, the real magnitude of the impact of the 'weekday' is small and often not clarified. Focussing on the Monday vs Friday effect for example, the risk of death increases from 0.55% to 0.82%. What this means is that 370 patients need to be moved from Monday to Friday for one further death to occur. This way of presenting the numbers is certainly much less exciting that saying that there is a 44% higher chance or death if the operation were to be moved to Friday.
Competing interests: No competing interests
I am not of the belief that it is only surgical patients who do badly through poor attention over a weekend. In my third decade as an Obstetrician and Gynaecologist , I have observed the busiest days I have ever worked are on Easter Monday and the day after Boxing Day . Why ? Because a tranche of patients have been left in hospital with only their most immediate medical needs attended to for three or four days - The attending medical staff over the preceeding days seemingly having being paralysed by torpor.
This state of affairs desperately needs correcting , but how ? I very much doubt it will happen by legislation. Why ? Because good clinical care comes from good clinicians taking ownership of their patients conditions. A fundamental improvement in care of patients at weekends will most likely occur if good clinicians are permitted the opportunity to demonstrate how good care is provided - and that others follow their lead
Competing interests: No competing interests
Aylin and colleagues offer an interesting analysis which provides further evidence that the weekend management of postoperative patients could be improved [1], and moves to further strengthen the argument that the NHS should deliver a 24/7 service [2].
It is a shame that Saturday and Sunday patients were grouped for analysis. If they had been analysed separately, one would have expected the Sunday patients to have lower mortality than those whose operation was performed on Saturday, needing only to survive one day of the “weekend effect” instead of two. In fact, if the observed differences in survival are thought to be related to post-operative factors (particularly the 48 hour window described by Cavaliere et al [3]) the highest risk patient should be the one last on Friday’s list – required to survive the entire weekend before the normal team return.
The media reaction to this article, however, fails to appreciate that the authors conclude “the reasons behind this [increased mortality] remain unknown” [1].
Although the article suggests that the increased mortality could be due to reduced and/or locum staffing, newspaper reports jump to lay the blame at the feet of the junior doctors working at the weekend.
“It is what doctors don’t tell you: avoid falling sick over the weekend, when senior doctors are off duty and hospitals are run by a skeleton staff” [4] leads The Independent, painting a picture of a demonic horde of junior doctors, leaderless, running amok through the hospital in a scene akin to William Golding’s Lord of the Flies.
Both of the hospitals (forgive my inexperience) that I have worked in have reduced numbers of junior doctors caring for surgical inpatients over the weekend compared to the week. Statements such as "The junior doctors, they're always around, but they're not the ones making a difference here" [5] from Dr Foster’s Roger Taylor (2011), are misleading and unhelpful, and serve to undermine the public’s trust in junior doctors.
Junior doctors do not plan the staffing levels in hospitals; we do not want to work in under-supported conditions, and we did not design the now infamous “EWTD”.
The vast majority of junior doctors I know return home from a busy weekend shift having worked hard, fighting fires to try to keep their patients well until Monday.
It is time that senior NHS figures moved to defend junior doctors for the hard work that they do put in out of hours.
1. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ 2013;346:f2424
2. Should the NHS work at weekends as it does in the week? Yes. BMJ 2013;346:f621
3. Cavaliere F, Conti G, Costa R, Masieri S, Antonelli M, Proietti R. Intensive care after elective surgery: a survey on 30-day postoperative mortality and morbidity. Minerva Anestesiol 2008;74:459-68.
4. http://www.independent.co.uk/life-style/health-and-families/health-news/...
Competing interests: I am a current Foundation Year 2 doctor.
Re: Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics
Dear Editor,
The pattern of results in this interesting paper shows a (non linear) increase in odds ratio for death within 30 days throughout the normal working week with a maximum at the weekend.
The authors do not provide a hypothesis as to why this is but some people have postulated that these results can be explained by increased risk in the period following the day of surgery due to reduced levels of care at weekends.
This seems not to be a plausible explanation because if it were true we would not expect to see an increasing trend of mortality throughout the week and we would expect to see the highest mortality on Friday (with patients exposed to the longest period of risk over the whole weekend) and a lower mortality on Saturday (with patients exposed to risk for only one weekend day).
The results are, however, consistent with an increasing risk due to the cumulative effects of normal hospital working over the days preceeding the day of surgery, starting with no increased risk on Monday, then a cumulative increase in the log odds ratio of approximately 0.118 per day (if I have calculated it correctly!) reaching a peak on Saturday after five days of accumulated extra risk.
So perhaps the explanation for this pattern of results does not lie in what happens after the operation is carried out but in some kind of accumulated 'stress' - either in the hospital system or in its staff - in the days preceeding the day of operation?
Competing interests: No competing interests