"If you go to Walmart or Target, you expect the same service on a Sunday as you do on a Wednesday," said Paul E. Marik, a physician and researcher at Eastern Virginia Medical School in Norfolk. "Unfortunately, if you come to a hospital, we don't function the same way." Marik coauthored a new study showing that, after adjusting for severity of illness, patients admitted to an ICU over the weekend have an 8% higher risk of death than patients admitted on weekdays. Taking sampling variability into account, the increased risk might be as low as 4% or as high as 13%.
Cavallazzi and colleagues examined 10 studies that compared mortality rates according to the day of admission (weekdays versus weekends), the time of day (on weekdays, daytime versus nighttime), or both. A combination of changes in "off-hours" staffing and organizational structure, including "a decreased physician-to-patient ratio, unavailability of board-certified intensivists, physician fatigue, and difficulty in obtaining complex diagnostic tests or therapies," may explain the higher risk.
No significant association was found between weeknight admission and increased mortality. "The greater availability of clinicians and support staff during the week as well as the shorter 'downtime' could account for this finding," the authors noted. Differences in study design and statistical analysis between the studies may also have obscured results.
Ramon Lavandero, a professor at the Yale University School of Nursing and communications director of the American Association of Critical-Care Nurses, cautioned against drawing strong conclusions from the study but added, "We should continue to seek evidence about the factors that influence optimal patient outcomes and recognize that staffing is one of many factors."
Eileen Lake, a professor of nursing and sociology at the University of Pennsylvania, said she's found surprisingly little research on off-hour nurse-staffing changes and agreed that more research is needed. Preliminary data from her study of 70 U.S. neonatal ICUs show that staffing ratios are slightly lower on weeknights and lower still on weekends. (The meta-analysis by Cavallazzi and colleagues excluded studies involving pediatric patients.) She emphasized the importance of staff nurses' input to ensure that the most effective solutions are instituted.
"Hospitals should function the same at night and on weekends as they do on weekdays," added Marik. "Patients deserve the same level of care, no matter what the hour."-James M. Stubenrauch