Concrete Evidence of Off-Peak Effect

More evidence and more scientific studies are showing that the weekend effect, what we refer to as off peak, really does exist and really does increase mortality rates.

Please see the article below that was published in The Burrill Report last month.

PUBLIC HEALTH | March 05, 2009

The Weekend Effect

Patients with gastrointestinal bleeding admitted to hospitals outside the workweek have a higher death rate.

A growing body of health services research has pointed to an association between admission to hospitals on the weekend and increased mortality. This so-called ‘weekend effect” has been attributed to reduced hospital staffing and access to specific intensive treatments and procedures. Two recent studies published in the journal Clinical Gastroenterology and Hepatology build the case for this weekend effect.

In one study, researchers found that patients with non-variceal upper gastrointestinal hemorrhage admitted on the weekend had higher mortality and lower rates of early endoscopy. In addition, patients with acute variceal hemorrhage admitted to non-teaching hospitals also had lower utilization of early endoscopy but no difference in survival.

“Although previous studies have demonstrated differences in outcomes between weekend and weekday admissions, there has been limited analysis focusing on patients with GI bleeding, a common medical emergency that carries significant disease and death,” says Ashwin Ananthakrishnan of the Medical College of Wisconsin and lead author of the study. He says the finding of higher mortality rates for patients suffering from non-variceal upper gastrointestinal hemorrhage on the weekend underscores the need for research into identifying the reasons for the weekend effect and to institute appropriate interventions.

The researchers data from a cross-sectional study using the Nationwide Inpatient Sample 2004, a total of 28,820 discharges with acute variceal hemorrhage and 391,119 discharges with non-variceal upper gastrointestinal hemorrhage were identified. Admissions were considered to be weekend admissions if they were admitted between midnight on Friday through midnight on Sunday.

On analysis, non-variceal upper gastrointestinal hemorrhage patients admitted on weekends had 22 percent higher adjusted in-hospital mortality and were 36 percent less likely to undergo early endoscopy within one day of hospitalization. There was one excess death for every 143 patients admitted on a weekend. Weekend admission was not predictive of in-hospital mortality in patients with acute variceal hemorrhage, but was associated with lower likelihood of early endoscopy in non-teaching hospitals. Early endoscopy was associated with significantly shorter hospital stays and lower hospitalization charges.

A separate study published in Clinical Gastroenterology and Hepatology found patients admitted to the hospital on the weekend for peptic ulcer-related hemorrhage have higher mortality and more frequently undergo surgery. Although wait times for endoscopy are prolonged in patients hospitalized on the weekend, this delay does not appear to mediate the weekend effect for mortality, researchers from the Univeristy of Calgary report.

“In addition to increased mortality and higher rates of surgical intervention, patients hospitalized on the weekend experienced greater hospital charges and length of stay than those admitted during weekdays,” says Robert Myers of the University of Calgary and lead author of the study. “Future studies should explore alternative processes of care that may mediate these effects, as upper gastrointestinal bleeding represents a considerable clinical and economic burden.”

http://www.tjols.com/article-1176.html

Off Peak Makes News

Dr. Hamilton, the principal investigator for our research, recently spoke at a Faculty Forum at Midwestern State University. Not only did the local media outlet pick up the story but also the National American Nurses Association. Please find the article below.

Dean researching off-peak hour hospital death rate

By Ann Work
Thursday, April 9, 2009

Dr. Patti Hamilton has already found one practical take-away from her research on nursing crises that occur at hospitals on nights and weekends.

Hamilton, a registered nurse and dean of graduate studies at Midwestern State University, learned from interviews with 30 nurses that it’s best for patients to always bring a family member with them as an advocate for their care.

“One nurse in a critical care area said, ‘I’m so glad when families are in the room. Then I know I can’t ignore them,’ ” Hamilton said Tuesday when she presented her initial research findings at MSU’s University Faculty Forum. “So take somebody with you.”

Hamilton is in the beginning stages of a $300,000 study investigating why 23 of the 100 leading causes of death in hospitals happen most often during nights and weekends.

“We’re sure it’s so. Why it’s so is still unknown,” Hamilton said. With a grant from the Robert Wood Johnson Foundation, Hamilton has conducted interviews with nurses for the past four months at two Texas hospitals.

Initial research shows that nurses who work off-peak hours are often the most inexperienced. They also report difficulty with on-call doctors who refuse to answer nighttime phone calls or to respond as asked, which requires nurses to take on duties beyond their ability levels.

Problems in hospitals in their off-peak hours aren’t new. But when Hamilton saw that magazine editors were including survival tips for hospital stays alongside tips for escaping plane crashes or bear attacks, she decided it was time to find out more.

After studying a neonatal unit, she learned that the “weekend effect” is greatest at hospitals of moderate size — not at the very biggest hospitals and not at the smallest.

The largest hospitals have large, competent staffs; small hospitals are quick to transfer difficult cases. It’s the medium-sized hospitals that may keep a patient who is having problems, thinking its staff can handle it.

“We’re not sure, but it worries us,” Hamilton said.

Nurses also reported serious communication problems with physicians and other nurses. The problems continued, even after the nurses were given a half-day training session to help them.

Often, nurses denied having problems if they worked evenings or weekends, but if given space on a survey at the end, would scrawl out horror stories. “We couldn’t explain this,” Hamilton said.

Interviews with nurses in stressful intensive care units showed that the younger, less experienced nurses are often scheduled to work the off-peak hours. When an emergency arose, they asked themselves, “Who can I wake up? Who will be nicer to me?” During the day, doctors were readily available; at night, doctors often couldn’t be awakened or wouldn’t come in to help.

Hamilton also learned that teamwork was difficult for nurses when they had to work with nurses who came from different ethnic groups, spoke English with different types of phrasing, or had different training. Supplies often ran out during the night shift or on weekends, requiring nurses to drive across town to replenish.

Nurses cited difficulties with 12-hour shifts, particularly during the hours from 3 a.m. to 5 a.m. Because of family responsibilities, it was typical that many nurses reported for work with only two to four hours of sleep before putting in a long day.

“I am astounded at what they are able to do with what they have,” Hamilton said.

Interviews will continue through Aug. 31, 2010; results will be disseminated quickly and broadly, she said.

Education reporter Ann Work can be reached at (940)763-7538 or by e-mail at worka(at)TimesRecord News.com.

http://www.smartbrief.com/servlet/wireless?issueid=B3AF148E-1AC4-4CAD-80AB-5946AE838CF5&sid=b4cd3494-1afe-48c3-9485-369c894eef4b

Breaking the Ice

I have decided to retell a story that a SICU nurse told me. I am going to use the first person narrative in order to keep things interesting yet anonymous.

I arrived for my normal 7 to 7 on Sunday morning. I got report from the night nurse and was given 2 relatively stable patients with the expectation of another admit. A couple of hours into my shift we, the SICU, received a patient from the OR who was unstable and needed labs and a chest x-ray immediately. Because I was light on patients, I was charged with him.

When I tried to order both the labs and x-ray, I ran into a roadblock; the patient was not in the computer system. Obviously he was a patient, he’d just come from the OR. Why in the world was he not in the system? I called down to admitting to see if they knew or could enter him into the system. They couldn’t because apparently he had come through the ER. I called the ER to ask them to put him into the system; they sent me back to admitting.

By the time I finished this game of ping-pong, there had been a 20 minute delay in care and the doc on call was furious and of course took it out on me. We eventually got everything straightened out and the patient officially admitted and stabilized.

This should never have happened and would not have happened during the normal work week. On the weekend, there is less auxiliary staff and services and unfortunately mistakes happen. Given, this is not something that happens every week or even every month, but it happened and who’s to say it won’t happen again.

Narrative Inspiration

We want to hear real stories from real nurses. We want to know when and how it’s hard, easy, frustrating, and fulfilling to care for patients at nights and on the weekends. 

While conducting this research, a colleague of mine visited a local hospital. As she was walking down the hallway a couple of nurses passed her proclaiming,

“That happens every weekend.”

What was that nurse referring to? What happens every weekend? Is there a shortage of supplies? Are doctors hard to reach? Did a nurse or two not show up for their shift?

These are the questions we are trying to answer. These are the experiences we want you to share with us.

Instructions for Nurses Posting on this Blog

First of all, I would like to thank all the nurses whom have graciously agreed to participate in our research study. As direct care nurses, you have first-hand knowledge of the barriers to care on nights and weekend, and thus your experiences are vital to our research. We hope to use the data we collect to address and ultimately assure that nurse work environments are optimal, no matter what day of the week or time of day.

When you post a comment about your personal experience while working during off-peak hours, please remember not to use patient names, names of co-workers, or the name of the hospital at which you work. Also, please only use your first name or a nickname.

Again, thank you for your time and support of this important research.

Welcome

We are researching how and why off-peak work environments are different, and how they affect nurse's work and patient care. Our research method of choice is institutional ethnography (IE). IE will allow us to determine the organizational factors that influence nursing and thus patient outcomes. We know from previous research that patients are more at risk during off-peak hours, nights and weekends. This study aims to determine what factors within the hospital environment influence or cause these outcomes. We seek to gain a more thorough understanding of the nurses' work and experiences.

My name is Katy Krottinger, and I am the Grant Coordinator for this project and will also be maintaining this blog. If you are interested in knowing more about our findings, please email me at katharine.krottinger@mwsu.edu.