Solving the weekend effect for patients in the hospital

If you knew you were going to be admitted to the hospital for a serious and unexpected medical problem, which day of the week would you pick?

It sounds like a silly question. You don’t get to pick the day you will become sick, of course. It’s unexpected. And why should it make a difference? Isn’t a hospital with a 24 hour nursing staff and on call physicians the safest place you can be? Not always.

Patients hospitalized Friday night or over the weekend stay longer than patients admitted for the same problems Monday through Thursday. This adds unnecessary costs to their medical treatment. But the problem is more than financial. These patients also face a greater chance of experiencing a complication. And the extra day can even cost patients their lives. It’s a risk that most people don’t realize and most doctors don’t acknowledge.

Journal of the American Medical Association study found that hospitalized patients who suffered a cardiac arrest during nights and weekends were less likely to survive. A British study found that patients who were admitted to a hospital on a Sunday faced a 16 percent higher risk of dying within a month than those admitted on weekdays. And Canadian scientists found that ischemic stroke sufferers admitted to hospitals over the weekend were more likely to die within seven days than those admitted during the week.

The obvious question here is: Why? The answer is a complicated mix of economics and medical culture.

During the week, all diagnostic and interventional services are open. On the weekend, many of them shut down except when staff members are called in to care for a life-threatening problem. The on call staff understands that when a patient’s life depends on their expertise, they need to stop what they are doing and drive to the hospital. But the culture of medicine supposes that making a stable patient wait until Monday won’t be a problem.

As a result, the pace of medical care for patients on the weekend slows from a run to a walk. On Saturdays and Sundays, many stable patients “hang out” in hospital beds. Therefore, it takes more time to determine their diagnosis and treat them. It seems innocuous. But for some patients, waiting until Monday morning allows their disease to progress. And each passing day increases the likelihood that a patient will experience a hospital-acquired infection or medication error.

There is also the risk of delirium — sudden and severe confusion. Hospitals are continuously noisy and bright, and an added night of sleep disruption can induce delirium, requiring on average three extra days in the hospital and up to six months to recover fully.

No matter the reasons, the waiting game has proven dangerous and costly. So, what can be done about it?

Studies like the ones referenced earlier make it clear that what some call the “weekend effect” can be harmful to patients. But the studies don’t provide proven solutions. Here are a few things we at Kaiser Permanente have learned can be done to decrease the added risk of a weekend hospital stay.

Most hospitals provide sophisticated diagnostic testing and interventional procedures for two groups of patients: those staying in the hospital overnight and those being treated on an outpatient basis. These less urgent outpatient studies and procedures are typically scheduled Monday to Friday.

In contrast, the weekends are unscheduled with technical staff and doctors are only made available should an emergency arise. By scheduling some of the weekday patients on the weekends and spreading out the staffing over seven days, the necessary teams are available every day to provide rapid care to these less urgent inpatients. Even though their medical problems are stable, the sooner these patients are diagnosed and the more rapidly they are treated, the faster they can recover and the lower the risk of complications.

The lack of clinical services on the weekends is not the only thing that causes a problem.

Physicians tend to come to the hospital later in the day on weekends. And the coordination of care that happens on weekdays diminishes on Saturday and Sunday. Solving this requires bringing all of the specialty consultants together and achieving consensus on when they will begin their morning rounds: seven days a week. And on weekends, physicians often wait until the next morning to check on the results of the tests they ordered earlier in the day. Making certain that follow up is completed each afternoon, whether by that individual or a colleague, speeds up the healing process.

It’s no surprise that having more doctors and technicians on hand over the weekend improves patient outcomes. And maximizing the performance of high capital facilities seven days a week isn’t new to business leaders. But making this change in expectations will clash with medical culture.

Expanding weekend hours and raising expectations will impact the lives of physicians and staff in ways they are likely to resist. But with reduced payments from Medicare and increasing demands for lower prices through the health insurance exchanges, expectations are going to change.

Since these agreements will be inconvenient for people, the hospital could provide financial incentives to physicians and staff for improved quality outcomes to ensure the changes are being carried out effectively and collaboratively.

And once hospitals change their practices, the real winners will be patients and their families.

Robert Pearl is a physician and CEO, The Permanente Medical Group. This article originally appeared on Forbes.com.

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  • Dr. Drake Ramoray

    To answer the title question of the article I would say a Monday or Tuesday in May or June. Don’t want the new interns taking care of you in July either.
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    Physicians tend to come to the hospital later in the day on weekends. And the coordination of care that happens on weekdays diminishes on Saturday and Sunday. Solving this requires bringing all of the specialty consultants together and achieving consensus on when they will begin their morning rounds: seven days a week.

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    That is true I often see patients later in the day on the weekends for follow up evaluations. As for consensus on when morning rounds begin 7 days a week, good luck with that. I can’t even get the docs at either of the hospitals where I have privileges to actually call me for a consult in the first place. I always get a phone call from the floor secretary or nurse who doesn’t know the first thing about the patient when I ask any questions. This just adds to the fact that I get the consult the next day between 9-10 AM (after the nurse shift change) for a patient admitted mid-afternoon the previous day. If I was notified of the consult the day before I would see them either that evening if necessary or first thing in the morning. Not to mention I have to take time during my full clinic to see if I have to see the patient at lunch, after patient hours in the evening, or the next morning. Before you ask, I don’t have the inpatient volume to justify altering my outpatient schedule as some weeks I will get only 1-2 or even no consults.
    With our current system I hear about the patient somewhere between 6-20 hours after admission from someone who doesn’t know anything about the patient (sometimes they don’t even have the reason for consultation correct (common with hypo vs. hyperthyroidism). I have brought this up at med staff meetings (as have the older partners in my practice) and nobody seems to care. Got to click those boxes for your orders and move on to the next patient.

  • fatherhash

    start paying double on weekends and watch the “weekend effect” disappear.

  • azmd

    “Making the change in expectations will clash with medical culture.” It is not clear to me how expecting to work less hard on the weekends is unique to “medical culture.” All workers, whether medical or not, need a break at some point during the week.

    Absent any specific details which would point to the contrary, Dr. Pearl appears to be suggesting that physicians work at full intensity, seven days a week, and without significant direct financial remuneration (at least that is the usual meaning of “financial incentives for improved quality outcome”).

    This is obviously a recipe for even more rapid burnout among physicians, which one would hope Dr. Pearl is aware would also adversely impact the quality of patient care.

    Certainly scheduling doctors on flex-time to provide for even coverage throughout a seven day week by physicians working offset shifts seems like it would be a good solution, and would probably be embraced by many doctors. Curiously, I don’t see that mentioned anywhere.

  • Suzi Q 38

    After reading this, if I need a surgery and can choose the day and time, I will not check in on a Friday. Maybe Tuesday is a better day, with plans to get out ASAP.

  • Kaya5255

    Hospitals still haven’t learned that if you want to make money, you have to spend it. On Call just doesn’t work! Hospitals are open 24/7 and every department needs to be open and adequately staffed.
    There is no excuse for a hospitalized consumer to have to wait for services, regardless of the day of the week.
    Get in and out of a hospital as quickly as you can!! Your life depends on it. The longer one is hospitalized the greater your risk becomes of acquiring a serious infection.