Chance of dying in hospital on weekend higher — but why?

Health officials acknowledge patients admitted to hospital on a weekend face a slightly higher risk than those admitted during the week.

By: Diana Zlomislic News reporter

Are you more likely to die in hospital this weekend?

Possibly.

Nearly 12 years after two Toronto researchers established the phenomenon of “the weekend effect,” doctors acknowledge patients admitted between Friday and Sunday face a slightly higher risk of death than those admitted in the week. But physicians are still at odds over how to address the grim statistic.

There is no “burning platform” for change because there are too many variables for what might cause the effect, said Dr. Chaim Bell, a general internist at Mount Sinai Hospital who co-authored the landmark paper with Dr. Donald Redelmeier of Sunnybrook Health Sciences Centre.

At the time, Redelmeier worried his patients were not getting the same quality of care seven days a week, so he analyzed 10 years of data from Ontario hospitals to see if his hunch was correct. Bell was a medical fellow.

Studies in the U.S. and Australia have since replicated their 2001 findings. A few have disputed them. In June, an article in the British Medical Journal found the “weekend effect” applies not just in emergency care but also to elective surgeries. Researchers found patients were roughly 45 per cent more likely to die on a Friday than a Monday.

After adjusting for patient age, overall risk and other factors, one of the study’s authors said they were left with one possible explanation.

“This increasing trend in mortality rates is due to poorer quality of care at the weekend,” Dr. Paul Aylin said.

Redelmeier and Bell tried to measure whether staffing levels influenced the results, but getting the data proved difficult. There is no central database where hospitals submit such information. They canvassed centres directly but not all were co-operative, so Redelmeier took aerial shots of staff parking lots during the week and on weekends.

“We didn’t have a helicopter but you go to the very highest room in a hospital that overlooks the staff parking lot,” he said. “We didn’t do that in a systematic manner but thought the visuals were pretty impressive. Parking lots were not nearly as full on weekends as weekdays.”

Staffing in emergency rooms and obstetric wards remains largely unchanged in most GTA hospitals seven days a week, according to a recent informal survey conducted by the Star. But the number of specialists and services operating on weekends is significantly reduced, local researchers say.

Internal medicine wards at teaching hospitals in the city operate on average with a third of the doctors on weekends compared to weekdays, according to an analysis published last week on Healthy Debate, a website run by health-care workers in Ontario and Alberta.

“I don’t want to make it sound like this is some big public health menace,” said Dr. Kaveh Shojania, a Sunnybrook hospital clinician and director of the Centre for Patient Safety at University of Toronto. “The effects are small but they’re real.”

The literature should not keep people from going to hospital on weekends, he urged.

“Getting a test in eight hours instead of one hour is usually fine,” he said. But if it’s Saturday morning and a patient is told a test is not available until Monday, “it’s OK to ask, ‘Is that really safe?’ That would be a legitimate thing to ask, for family members and for patients.”

The Star surveyed teaching hospitals across the city, asking them to distinguish between the number of residents and doctors on duty during a recent Tuesday and Saturday. Only one responded with hard figures as requested, showing an overall slight decrease in staffing on weekends and fewer residents on duty.

More and more hospitals are now accounting for another phenomenon — a double whammy to the weekend effect — tied to young, inexperienced doctors-in-training who begin their residencies in July.

Toronto medical malpractice lawyer Paul Harte said in his nearly 20 years of practice, his firm regularly sees a peak in claims that month.

Dubbed “The July Effect” in North America and “The August Effect” in Britain, teaching hospitals have informally restructured shifts to account for the inexperience, says Dr. Robert Sargeant, a general internist at St. Michael’s Hospital.

“We are called upon as the attending physicians to be that much more on top of things and more present in July and August than perhaps we need to be in May and June,” he said. “The learning curve is very steep.”

John Lewis, a registered nurse from Hamilton, lost his 11-year-old daughter Claire in 2001 after a first-year resident was assigned to her care following a Friday surgery to remove a benign brain tumour. He failed to take immediate action after she showed signs of increased intracranial pressure. She stopped breathing and was intubated Sunday night. She was pronounced dead on Monday morning.

“Her death kind of strikes me as a classic weekend event,” Lewis said. The resident was “left on his own to make decisions he shouldn’t have been making. There was a lack of specialists. It added up to this absolute mess of people who didn’t really know what they were doing.”

Six months later, Hamilton Health Sciences Centre issued an apology.

An intervention even 30 minutes before Claire stopped breathing “could have resulted in a different outcome,” the hospital stated.

Despite the lack of a “burning platform,” Bell and Redelmeier’s work and the additional research it spawned have had some local ripple effects.

No matter what day of the week, patients suffering acute heart attacks at Sunnybrook hospital, for example, may be seen by a cardiology team in the catheter lab for a special procedure to unclog arteries that beats the effect of clot-busting drugs, Dr. Shojania said.

And two years ago, Toronto Western Hospital opened one of 30 specialized stroke centres across the province that treats patients seven days a week.

The unit is staffed by nurses, a rehab team that consists of an occupational therapist, a physiotherapist, dietician, speech and language pathologist and social worker.

Sargeant at St. Michael’s sees another solution to the weekend effect: compelling general practitioners to open their doors to patients on Saturdays, as banks have for customers.

“If you want to look for continuity of care and the whole purported benefit of these community care centres that have ended up falling on their faces, that might be a good place to start,” he said.

“Instead they all come to the emergency department because their doctor is not working.”