Weekend effect

Although this is a controversial area, the balance of opinion is that the weekend (and bank holidays) have a deleterious effect on patient care (and specifically increase mortality)—based on the larger studies that have been carried out.

They found "Weekend admission was not associated with significantly higher in-hospital mortality, readmission rates or increased length of stay compared to the weekday equivalent for any of the six conditions".

However, in 2010, Clarke et al.,[2] in a much larger Australian study of 54,625 mixed medical/surgical non-elective admissions showed a significant weekend effect (i.e. worse mortality) for acute myocardial infarction.

Thus the authors pointed out that "admission at the weekend was not independently predictive in a risk model that included Illness Severity (age and biochemical markers) and co-morbidity".

After adjusting for diagnosis, age, sex, race, income level, payer, comorbidity, and weekend admission, the overall odds of mortality was higher for patients in hospitals with fewer nurses and staff physicians.

In a 2016 study of 12 Italian Acute Medical Units, Ambrosi et al.[9] found that elderly patients were six times (95% CI 3.6-10.8) more likely at risk of dying at weekends.

The lowest mortality rates were observed in hospitals with higher levels of medical and nursing staffing, and a greater number of operating theatres and critical care beds relative to provider size.

Aylin et al.[17] (2013) in the UK, investigated 27,582 deaths (within 30 days) after 4,133,346 inpatient admissions for elective operating room procedures; overall crude mortality rate was 6.7 per 1000).

However, in 2013, Powell et al.,[26] in the US, analysed 114,611 ED admissions with a principal diagnosis consistent with sepsis, and found that the difference for overall inpatient mortality (in terms of the weekend) was not significant (17.9% vs 17.5%, p=0.08).

Participants were adults, 65 years+, and admitted through the emergency department with six common discharge diagnoses (acute myocardial infarction, congestive heart failure, stroke, pneumonia, hip fracture, gastrointestinal bleeding).

The authors concluded "survival rates from in-hospital cardiac arrest are lower during nights and weekends, even when adjusted for potentially confounding patient, event, and hospital characteristics".

However, also in 2007, in a much larger US study (of 231,164 AMI patients), Kostis et al.[59] found that the difference in mortality at 30 days was significant even after adjustment for demographic characteristics, coexisting conditions, and site of infarction (OR = 1.048; 95% CI 1.02-1.08; p<0.001).

Similarly, also in 2010, in South Korea, in another large study (97,466 patients), Hong el al,[62] found the 30-day fatality rate was insignificantly different after adjustment for medical or invasive management (OR = 1.05; 95% CI 0.99-1.11).

In 2014, in another Canadian study (of 11,981 AMI patients), O'Neill et al.[69] found that, after adjusting for baseline risk factors, the hazards ratio for mortality was non-significant (OR = 1.06; 95% CI 0.82-1.38).

When comparing 'in-hours' (40%) to 'out-off-hours' cannulation (60%), there were no significant differences in central nervous system complications, haemorrhage (extra-cranial), cannula repositioning, conversion from venovenous to venoarterial, mortality on ECLS, or survival-to-discharge.

AMI is a condition where a weekend effect might not have been predicted (i.e. a fairly random acute disease, traditionally looked after on a CCU where working patterns are usually similar through the week).

UGIB (Variceal haemorrhage alone) In a Canadian study of 36,734 patients with AVH alone, Myers et al.[103] (2009—after adjusting for confounding factors, including the timing of endoscopy - found that the risk of mortality was similar between weekend and weekday admissions (OR = 1.05; 95% CI 0.97-1.14).

In the multivariable analysis, weekend admissions were associated with higher early mortality (OR = 1.14; 95% CI 1.02-1.26) after adjusting for age, sex, comorbidities, and medical complications.

In China, in 2012, Jiang et al.,[144] in a much smaller study (of 313 patients with ICH) found that weekend admission was not a statistically significant predictive factor of in-hospital mortality (p=0.315) or functional outcome (p=0.128).

No consistent association between outcomes and staffing was identified, although trusts that complied with recommended levels of consultant presence had a perineal tear rate of 3.0% compared with 3.3% for non-compliant services (OR = 1.21; 95% CI 1.00-1.45.

The authors went on to make a prediction regarding the possible benefits of removing the 'weekend effect': "The results would suggest approximately 770 perinatal deaths and 470 maternal infections per year above what might be expected if performance was consistent across women admitted, and babies born, on different days of the week."

They found, on multivariate analysis, mortality was associated with patient age (10 years: OR = 1.31, p < 0.01), severity of illness (extreme: OR = 34.68, p < 0.01), insurance status (Medicaid: OR = 1.24, p < 0.01; uninsured: OR = 1.40, p < 0.01), and weekend admission (OR = 1.09, p = 0.04).

In a study of 63,768 patients with an ischaemic lower limb in 2014, Orandi et al.[186] found no statistically significant association between weekend admission and in-hospital mortality (OR = 1.15; 95% CI 1.06-1.25; p=0.10).

There are several alternative explanations for this effect, including the hypothesis that an increase in mortality is due to a different (frailer) demography of patients being admitted at the end of the week (e.g. Friday and Saturday).

In 2015, Leong et al., in an uncontrolled study of elderly medical patients in the UK, stated "introduction of seven-day consultant working was associated with a reduction in in-hospital mortality from 11.4% to 8.8%".

In 2013 in France, Bejot el al. found that onset during weekends/public holidays was associated with a higher risk of 30-day mortality during 1985-2003 but not during 2004–2010; before and after the introduction of a dedicated stroke care network.

In November 2013, the Academy of Royal Medical Colleges set out to address this matter in a document entitled Seven Day Consultant Present Care - Implementation Considerations.

In 2013, the NHS England (NHSE) Medical Director Prof Sir Bruce Keogh wrote that there is a clinical and compassionate argument for patient convenience.

Other doctors state that overall patients are unlikely to benefit,[195] and that limited NHS budget and resources would be better invested in providing better emergency care to improve mortality.

[201] The UK's main doctors union, the British Medical Association, is still negotiating, as they would like assurances that new contracts will safeguard against long working hours, and are fair for female employees and those with families.