Deaths from surgery increase from a low on Monday to a high on the weekend according to a BMJ study just released May 28, 2013. The researchers evaluated about 750,000 scheduled surgeries and suggest the likely explanation is poor quality care on Friday and weekends.
Friday surgery has a 44% increase in the odds of death within 30 days compared to Monday. Weekend surgery is worse with an 82% increase in risk.
The 3-in-1 hospital. All hospitals are divided into three hospitals because of nurse shift assignments, weekends, holidays and vacations. And, the tendency for senior staff to gravitate to the weekday shifts. The hospitals are:
- The day hospital
- Then night hospital
- The weekend and holiday hospital
The day hospital has a full staff with the most senior doctors and nurses available and the operating room working at optimal capacity.
The night hospital has a limited staff of doctors and nurses and limited operating room staff.
The weekend and holiday hospital — this problematic hospital is when the staff levels are low, the operating room is on a standby, the least senior nurses are working and the weekday doctors are replaced by on-call doctors usually doing double duty (often overworked, not familiar with the patients and sleepy from long night hours). Furthermore, on-call surgeons may try to delay treatment of surgical complications until weekday surgeons are available.
The real surprise in this study is that the death rate rises as the week progresses. The cause is not clear but some possibilities include fatigue, surgeons being less available to resolve hospital problems when at an outpatient clinic, afternoon golf, and possibly scheduling patients just discovered to have surgical problems that week in the ER (delay in care).
Another negative factor is the global surgical payment (surgeons receive one payment for a surgery including all pre- and post- surgical care). So, unless there is a very equitable system within a group the surgeons who round on weekends are not paid and have little incentive to do more than “howdy” rounds.
How to correct the problem:
- Hospital actions: spread the surgical service activity over more shifts and weekends. At least one third of nursing staff on any shift should have more than 5 years experience. Pay surgical hospitalists to attend to surgical patients when the primary surgeon is not in the hospital and to service the emergency room at any time.
- Surgeon actions: Provide the hospital with a surgical hospitalist who is at the hospital 24/7. Allow the surgical hospitalist to do surgery on patients admitted from the ER. Reduce the Friday and weekend workload with more physician staff on those days. Provide monetary compensation for covering doctors (not just payment in kind).
- Patient actions: Ask about whether there is an experienced surgical hospitalist available in the hospital at all times (not just a resident or medical hospitalist). If not, refuse elective surgery on Friday or on weekends.