29 Oct, 16 | by cgray
If you haven’t already, listen to Ellen Weber and Chris Moulton talk about the background to the weekend effect. Click HERE.
The UK Junior Doctors’ contract changes imposed by the government in order to shape their poorly defined ‘Seven Day NHS’ caused much debate and consternation surrounding the ‘weekend effect’, which seemed to be the main selling point for their demoralisation of a large proportion of the clinical workforce. Patients admitted over the weekend have been shown in several studies to fare worse than those admitted during the week (though indeed other studies suggest the opposite, or no difference at all!). The reasons for this are unknown however, and further research is being done to try to ascertain the cause of the ‘weekend effect’, whether particular patient groups are more at risk, and what, if anything, can be done to improve care. There is currently no evidence that doctor staffing levels are the cause and many feel that the effect simply reflects that patients who present over the weekend are, on average, more unwell. Other factors could include coding practice, or the availability of diagnostic resources at the weekend. However, all agree that if this effect truly exists, it’s important to establish why, as this will then determine whether it can be modified through changes to service provision or structure, in order to treat our patients better.
The abstract is here, but as always we’d advise you read the full paper to draw your own conclusions.
Major trauma networks have been around for four and a half years now, with the most severely injured patients preferentially triaged to the major trauma centres (MTCs). Patients arriving at these hospitals are usually managed from the start by a consultant-led trauma team, whether it’s 10am on a Tuesday, or 3am on a Sunday. Access to imaging, diagnostics, surgeons, and emergency operating staff and space are also a necessity for these centres, and MTCs are rewarded under a best practice tariff (BPT) for meeting quality standards.
Who was studied?
49,070 major trauma patients (adult and paediatric) presenting to the 22 MTCs around the UK. The inclusion criteria were admission for at least 3 days, requirement for high-dependency care, or death following arrival at hospital. Data were gained from the Trauma Audit & Research Network (TARN) database from the time the BPT was introduced, and for each hospital only from after the period they were operational as an MTC. From this the authors hoped to gain more complete data, as this improved after the BPT was put in place.
The group also subdivided patients later according to injury severity score (ISS), and whether they presented during the day (0800 to 1700), night (1700 to 0800), weekday, or weekend (Saturday or Sunday).
What did they find?
If we took the total data collected by the team, and condensed all these patients down so that they all presented to major trauma centres in just one week, 327 patients per hour would have turned up during weekdays, 333 per hour on weekend days, 210 per hour on week nights, and 419 per hour on weekend nights. Of course, the reality is much less, as these data were spread out over the period of the study, but these numbers give a good indication of major trauma frequency across the week.
Major trauma occurs more frequently on the weekend, and the patient characteristics demonstrate that those presenting at night are generally younger, with a higher male:female ratio. Less patients were conveyed via air ambulance at night, likely as a result of flying restrictions at these times.
Aside from a shorter length of stay in patients admitted during weekend nights compared with weekend days, there were no significant differences in the primary outcomes of length of stay, mortality, risk-adjusted excess survival rates, or Glasgow outcome score when comparing groups.
The study found that patients presenting with major trauma at night were more likely to be transferred into a Major Trauma Centre at night, which likely reflects daytime availability of diagnostics and specialist input at trauma units. There was no difference when comparing weekday to weekend day, however. There were also no significant differences found in the ISS >15 subgroup in any of the outcomes.
They found no evidence of a ‘weekend effect’ in this major trauma population.
What conclusions can we draw?
This is a large population multicentre observational study, with good data completeness, clear inclusion criteria, and clear outcome measures. There are no significant findings when comparing various groups, and the outlined definitions of day vs night are consistent with normal rota patterns.
The major trauma network is intended to provide well-staffed and resourced hospitals with senior specialists available 24/7 in order to provide severely injured patients with expedient access to necessary investigations and treatment, facilitating the best possible outcome. Whilst there is no evidence of a ‘weekend effect’ in patients presenting to MTCs, this does not mean that it does not exist elsewhere. If a difference had been found, however, this would suggest that staffing and resourcing in the hospital make little difference and that there are other forces at work.
Further work is needed on other populations, but it is reassuring that, unlike data from the US that trauma patients admitted at night are more likely to die, a large scale study of the UK major trauma centres has shown equivalent outcomes throughout the 24/7 hours of operation. It’s a fantastic achievement and one that all those working in centres across the country should be proud of.
If you haven’t been keeping up with the recent body of evidence surrounding the ‘weekend effect’, the Vice-President of the Royal College of Emergency Medicine, Chris Moulton, has provided a fantastic commentary to the Metcalfe paper. He’s also managed to give us a history lesson on the origins of the weekend at the same time. It makes for great reading.