By Debra Wood, RN, contributor
July 23, 2010 - Hospitals operate 24 hours a day, seven days a week, but outcomes may vary depending on which day of the week the patient was admitted. The risk of death is higher for intensive care patients on weekends, perhaps due to lower levels of staffing and intensity of care on those days, according to a recent study in the journal CHEST.
Linda Plank, RN, Ph.D., NEA-BC, helped develop the Baylor staffing model, in which nurses work weekends by choice.
“Hospitals are 24-hour facilities, but there tends to be a difference in staffing on weekends than Monday through Friday, and not just the nursing staff,” said Linda Plank, RN, Ph.D., NEA-BC, a lecturer at Baylor University’s Dallas-based Louise Herrington School of Nursing.
Rodrigo Cavallazzi, M.D., and colleagues at Jefferson Medical College at Thomas Jefferson University in Philadelphia and Eastern Virginia Medical School in Norfolk, Va., reviewed 10 cohort studies to assess the affect of off-hour ICU admissions on mortality. They found no difference for nighttime admissions but an 8 percent higher risk of death for patients admitted on the weekend, after adjusting for illness severity. Patients coming to the ICU during off-hours tend to be unstable and more susceptible to harmful effects of substandard care.
“A change in the organizational/staffing structure of an ICU and hospital over the weekend likely explains the increased mortality noted,” the authors wrote. “It is likely that a number of factors in combination, including a decreased physician-to-patient ratio, unavailability of board-certified intensivists, physician fatigue and difficulty in obtaining complex diagnostic tests or therapies, account for the higher risk of death over the weekend.”
As a remedy, the authors suggest making ICUs and hospitals in general more homogenous among days of the week.
"We should be cautious about the conclusions we draw and how we generalize this study's findings because of its significant limitations,” said Ramon Lavandero, RN, MA, MSN, FAAN, director of communications and strategic alliances for the American Association of Critical-Care Nurses (AACN) and clinical associate professor, Yale University School of Nursing. “At the same time we should continue to seek and analyze evidence about the factors that influence optimal patient outcomes and recognize that staffing is one of many factors."
"Staffing isn't just a matter of numbers,” Lavandero explained. “The American Association of Critical-Care Nurses' Healthy Work Environment Standards require that appropriate staffing ensure 'the effective match between patient needs and nurse competencies.'" AACN provides a list of their standards and a free team assessment tool on their Web site to help nurses align clinical performance.
Swedish Medical Center in Seattle has already taken the step to make their days homogenous throughout the week. Intensivists are onsite in the ICU on weekends, and the hospital’s e-ICU critical care physicians cover nights remotely, assessing patients through telemedicine cameras and by telephone. Hospitalists and surgical residents are available to respond in person during a code or to perform a procedure during the night. Nurse staffing also remains the same.
“It’s the same model every day, Sunday through Saturday,” says Renae Hawkins, RN, ICU supervisor at Swedish Medical Center’s First Hill Campus in Seattle. “Our patients’ acuity does not change over the weekend.”
Hawkins agreed that maintaining the same level of staffing improves patient care. MRI and CT scans are available during the weekend. However, some specialty diagnostics require calling in on-call personnel or services.
“We pride ourselves on patient safety, and things happen 24/7,” Hawkins. “We never want a patient to be in the situation that because they came to the hospital on a Saturday that they do not receive the same level of care as if they came in on Tuesday—not delaying procedures, not delaying any type of care because it’s a different shift, nurse or doc.”
Hawkins remembers a time when that was not the case, but now it is Swedish Medical’s standard. She arrives early to meet with night-shift staff to talk with them and ensure their needs are met.
Plank was involved 30 years ago in establishing Baylor University Medical Center’s “Two-days Alternative” staffing plan, which provided consistent nurse staffing on all seven days.
“It’s been a successful program and duplicated all over the United States,” Plank says.
However, even when nurse staffing remains consistent, a hospital may not have a radiologist onsite on the weekend to immediately review a scan. Special laboratory tests may need to wait until Monday, or the hospital may need to call someone in to run the specimen. Plank indicated, knowing that, a physician may wait to order the test.
“That leads to different practices and different care, when you don’t have the same resources,” Plank said. “Most places have made good decisions about what they have to have seven days per week, but other places have just said, ‘We only do this Monday through Friday, not Saturday Sunday,’ based on the personnel side, not the patient side.”
The CHEST article authors suggest further study is needed to learn to what extent a change in organizational structure during off-hours might affect outcomes, such as whether coverage by house staff or nurse practitioners is enough to overcome the higher weekend mortality risk or whether on-site intensivist coverage is needed.
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