Falls, other harm more likely

You can get a lot of data from more than 350 million hospital admissions. What you hope to find is that the care is equivalent from day to day, patient to patient. But that is not the case. According to a study published in April in BMJ, patients who are admitted on the weekend are more likely to fall or experience some other adverse event.1

Frank Attenello, the lead author of the study, said that while looking at data from a neuroscience outcomes research group — data that comes from 20% of the hospitals in the US each year — they wanted to see what was happening related to preventable outcomes that the Centers for Medicare & Medicaid Services (CMS) and other payers said they would no longer cover. “No one had looked at this data from such a large group of people, or what caused them,” he says. “There had been some previous press on weekends and that mortality was higher, but not other forms of harm.”

The data came from 2002-2010, and the authors found that just over 4% of patients had some hospital-acquired condition (HAC). Of the 20% of patients admitted on weekends, 5.7% ended up with a HAC, while the weekday patients had a rate of 3.7%. Even correcting for variables, the difference continued, Attenello says, and the risk for getting at least one HAC was 25% greater on the weekend. Patients with neurological conditions were at a 35% greater risk of developing a HAC, and the teaching status or size of the hospital also mattered, with smaller hospitals faring better. Older white men were more likely to have problems than minorities, women, and young people.1

The most common HACs were falls, pressure ulcers, and catheter-associated urinary tract infections (CAUTI). Interestingly, the rate of HACs increased “notably,” the study says, from 2002 to 2010. This could be due to increased surveillance, reporting, and attention to those issues.1

Hypothetical reasons

There are a lot of potential reasons behind these observations, says Attenello. At the time of these patient admissions, many hospitals did not have equivalent services available seven days a week, and there have been numerous studies that show not getting diagnostic testing done in a timely manner can impact outcomes. A patient who needs an endoscopy who is admitted on a Saturday night but has to wait until Monday for care could deteriorate, he notes. There is a lot more understanding that patients need to have access to equivalent care regardless of when they come in, and more effort by hospitals to ensure that it is available. Need a neuro consult on a holiday weekend? You’ll get it.

Secondly, there are often itinerant staff — particularly nursing — working on weekends. These are people who may be covering a shift for a friend for some extra money, or locums who make their living floating from facility to facility. Attenello says that these people may not know the intricacies of a particular facility — related to layout, policies and procedures, or even where medications are kept. That can lead to delays in care, or situations that lead to HACs. Imagine a nurse who does not know he or she has the power to suggest to a physician that a catheter is not needed? A patient who develops CAUTI as a result has a HAC he or she did not need to have.

Lastly, there are issues that you just can’t do anything about, he says. Ask a doctor who works in a hospital when the sickest patients come through the doors, and they will almost unanimously say, “the weekend.” “Most people do not plan when they come to the hospital,” he says. “But there are people who come in only when they finally have time, after they have gotten sicker and sicker.”

One finding that was crystal clear in the study was that the sickest patients were the most likely to fall, the most likely to get a pressure ulcer or infection — about twice as likely, he says.

There has been an increased focus on HACs since the people who make up this data were admitted to the hospital. CMS reported last year that there was a 17% reduction in some of the kinds of harm that Attenello and his peers looked at in this study. Does that mean the outcome of this study might be different in a few years’ time? Perhaps, he says. What is important is that you keep focusing on the overall infection and harm problem.

“Focus on the complications and avoiding them altogether,” he says. “If you get to the point where you have plucked all the low hanging fruit, then you can look at the variability of time.”

Resolutions

One thing you can be sure to do is to help people who are working on different units or are new to your hospital know the ropes and the rules. “Standardize things as much as possible everywhere. That way, if you are having nurses covering different areas, working with sicker patients, they all know what to do with everyone every time,” he says.

Attenello is a huge proponent of checklists for the most basic things, down to hand-washing. “Every hospital will have different risk factors, but every hospital will have something they can do to ensure that patients get the best care every day. It may be something very simple that helps you improve care and save money.”

For more information on this topic, contact Frank Attenello, MD, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA. Email: attenell@usc.edu.

Reference

  1. Attenello FJ, Wen T, Cen SY, Ng A, et al. Incidence of “never events” among weekend admissions versus weekday admissions to US hospitals: national analysis. BMJ. 2015 Apr 15;350:h1460. doi: 10.1136/bmj.h1460. Available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4398994/.