weekend effect - true or false?
TRANSCRIPT
Weekend Effect – True or False? ie evidence Base for 7D NHS
Dr Andrew Stein, Consultant in Renal Medicine, UHCW NHS England 7 Day Forum Member
BBC FOI Study – March 2014
• In England, 86 Consultants in average UK hospital on a Wednesday
• 8 on a Weekend Day
• Wednesday 4 December 2013, and the Weekend of 7 and 8 December
• Weekend is nearly 30% of week
Structure of Talk
• Arguments for 7DS
• Mortality literature
• Local Data - flow
• NHSE Data – mortality + flow
4 Arguments for 7DS
1. Weekend Effect: Mortality + Morbidity– Scientific literature
– Local flow data
– National (NHSE) data
1. Junior health professional supervision– Weekend is nearly 30% week
– Would you let a first year pilot fly a Jumbo in 30% week?
1. Monday chaos (hospital, GP and social)– 4h/12h = performance manage a nearly broken system that is unstainable
(financially)
– £2100 per patient per week acute
– £750 pw nursing home, £500 care home,
– £350 pw domiciliary care 4 x 1 hour per day
1. Its right, in a civilised society
Publication of Initial Findings Dec 2013
http://www.england.nhs.uk/wp-content/uploads/2013/12/forum-summary-report.pdf
The Forum’s proposals for …
•10 standards, describing the minimum standards of care patients should expect to receive 7DW•Use of contractual and other levers•“Got to want to do it”
… were accepted in full by NHS England’s Board. Now NHSE Policy
Weekend Mortality: Literature
Weekend Mortality: Non-selected Patients Ricciardi 2014 USA 48253968 Medicine 1.15 YesVest-Hansen 2015 Denmark 174192 Medicine Not stated Yes
Ricciardi 2011 USA 29991621Surgery (non-elective, NE)
1.1 Yes
Ricciardi 2016 USA 28236621 Surgery (non-elective) 1.08 Yes
Ozdemir 2016 UK 294602 Surgery (non-elective) 1.11 Yes
McClean 2016 UK 105002 Surgery (non-elective) Not stated Yes
Aylin 2013 UK 4133346 Surgery (elective, E) 1.82 YesMcIsaac 2014 Canada 333344 Surgery (elective) 1.51 YesMohammed 2012 UK 4640516 Surg (NE + E) 1.09 (NE) / 1.32 (E) YesGlance 2016 USA 305853 Surg (NE + E) 2.11 (NE) / 3.18 (E) YesBell 2011 Canada 3789917 ED Not stated YesCram 2004 Canada 641860 ED 1.03 YesAylin 2010 UK 4317866 ED 1.1 YesHandel 2012 UK 5271327 ED 1.27 YesPowell 2013 USA 114611 ED (sepsis) Not stated NoSharp 2013 Australia 4225973 ED 1.07 YesConcha 2014 Australia 3381962 ED Not stated YesBarnett 2002 USA 156136 ICU 1.09 YesBhonagiri 2011 Australia 245057 ICU 1.06 YesSchilling 2010 USA 166920 Other Not stated Yes
Freemantle 2012 UK 14217640 Other 1.11 (Sat) / 1.16 (Sun) Yes
Lee 2012Malaysia, Eng, Australia, USA
126627 Other 1.22 Yes
Ruiz 2015 Netherlands 2982570 Other Not stated Yes
Weekend Mortality: Selected Patients (1)Koike 2011 Japan 173137
Cardiac Arrest (out-of-hospital)
1.0 No
Kostis 2007 USA 231164 AMI 1.05 Yes
Isogai 2015 Japan 111200 AMI 1.22 Yes
Khera 2013 USA 1434579 STEMI Not stated Yes
Khoshchehreh 2016 USA 13988772STEMI (S) / NSTEMI (NS)
1.05 (S) / 1.3 (NS) Yes
Agrawal 2016 USA 3625271 NSTEMI 1.02 Yes
Singh 2015 USA 401571 PCI Not stated Yes
Barba 2012 Spain 289077 COPD 1.07 Yes
Suissa 2014 Canada 323895COPD / pneumonia
1.06 Yes
Nanchal 2012 USA 1143707 PE 1.17 Yes
Chang 2012 Taiwan 788011 Pneumonia 1.03 Yes
Shaheen 2009 USA 237412 Upper GI Bleed 1.06 Yes
Ananthakrishnan 2009 USA 419939 Upper GI Bleed 1.21 Yes
Abougergi 2014 USA 202340 Upper GI Bleed 1.11 No
Weeda 2016 USA 119353 Upper GI Bleed 1.09 YesNo Weekend effect in
nature
Weekend Mortality: Selected Patients (2)
James 2010 USA 963730Acute Kidney Injury
1.07 Yes
Sakhuja 2013 USA 3278572 Haemodialysis 1.18 Yes
Schmid 2014 USA 534011 Ca prostate 1.12 Yes
Lapointe-Shaw 2016 Canada 290471 Oncology 1.13 Yes
Hoh 2010 USA 599087 Stroke Not stated No
Smith 2010 Canada 274988 Stroke Not stated Yes
McKinney 2011 USA 134441 Stroke 1.05 Yes
Newcastle 1977 UK 297000Paediatric mortality
Not stated Yes
Hamilton 2003 USA 111749Neonatal mortality
Not stated Yes
Gould 2003 USA 1615041Neonatal mortality
1.12 No
Luo 2004 Canada 3239972Neonatal mortality
1.11 No
Palmer 2015 UK 1349599Perinatal mortality
1.07 Yes
Goldstein 2014 USA 439457 Paediatric surgery 1.63 Yes
Boylan 2015 USA 344989Fracture neck of femur
0.94 Weekday effect
193070066 Median 1.11
87% Positive
No/little Evidence for Higher Weekend Mortality
• SAH
• Upper GI bleed (variceal)
• Sepsis
• Paed/neon ITU (consistent)
• Laparoscopic appendectomy
• Liver Transplantation
• Trauma
• #NOF (Weekday Effect)
Other Factors Increasing Mortality
• Mondays Maggs, 2010
• Nursing levels, occupancy, W/E + influenza Schilling, 2010
• ITU Discharge at night Laupland, 2008
• ITU Discharge at W/E, and Mons, Fris Rollins, 2002
• Cons presence Acute Medicine Bell, 2013
• Trainees Ricciardi, 2014, 48,253,968 pts
Night Effect > Weekend
Effect
How do we know its real (1)?• All countries
– UK, USA, Australia, others
• All systems– Public, private and public-private
• Coincidence 10-15%?• Emergency and Elective• All stages of admission
– ED, gen med, ITU, specialist ward etc
• All ages• 200 million+ patients studied
How we know its real (2)?
• Medical and Surgical• Elective Surgery
– Risk increases Thurs and Fri– Ie failure to rescue towards end of week, and w/e
• Teams that normally provide 7D care– Eg CCU, ITU, Labour Suite, Nephrology– Also have a problem– Tells us alot
• So, may take a very big hammer to sort – ie not just a doctor problem
Even low risk
operations
Local Data - Flow
Adult UHCW ED Attendances
Monday Tuesday Wednesday Thursday Friday Saturday Sunday313 284 284 272 275 277 292
Average Volumes
V consistent -
Cultural C
hange?
Lack GPs??
Admissions from UHCW Adult ED Attendances
Monday Tuesday Wednesday Thursday Friday Saturday Sunday107 97 101 103 105 104 101
Average Volumes
Admissions
100-105/d - 7 days
UHCW Adult ED Attendances – Conversion Rate
Monday Tuesday Wednesday Thursday Friday Saturday Sunday34.3% 34.2% 35.5% 37.9% 38.2% 37.7% 34.5%
Average Volumes
We ‘perceive’
empty beds,
admit more?
UHCW Daily Admit-to-Discharge Balance
Monday Tuesday Wednesday Thursday Friday Saturday SundayAdmit 150 152 140 145 138 100 101
Discharge 133 150 150 147 165 102 79Balance -17 -1 10 1 26 2 -22
Average Volumes
Why don’t we flow?
It’s simple
NHSE (incl UHCW) Data: Mortality + Flow
• Emergency admissions nationally - Odds Ratio = 1.12
• UHCW for patient admitted at weekend compared to midweek - Odds ratio = 1.05 (low 0.95 - high 1.17)
• Weekend effect ? Yes, suggesting inc mortality, however, less than national OR
• Outlier? No
NHSE: UHCW Mortality within 30 days of admission (2015-16)
Our patients are more likely to
die if admitted at a weekend,
but less than national average
NHSE: UHCW Emergency Readmissions <7 days of Discharge (2015-16)
• For a patient readmitted on a Sunday compared to a Wednesday
• Emergency readmissions nationally - Odds Ratio = 1.40
• UHCW Odds Ratio = 1.20 (low 1.00, high 1.43)
• Increased likelihood of emergency readmission? Yes – higher than national odds
• Outlier? No – still within acceptable parameters
We readmit more on a
Sunday ?lack senior
support
NHSE: UHCW Readmission: National Comparisons
Our weekend
readmission tendency is
less than national
average
Conclusions
• There is overwhelming evidence of a ‘Weekend Effect’
• Ie you are more likely to die, if admitted as an emergency, or non-emergency, over a weekend, all countries, all ages
• Including UHCW
• This may reflect ‘failure to rescue’ by the health and social community (1°, 2° and social care)
• Cause(s) and reversibility uncertain
• Only whole system change will reverse it
