I recall participating many elective major procedures on Friday nights and Saturday mornings during my residency training, thinking to myself that not only should I be home, but this just can’t be good for the patient…can it? Well, apparently not.
A new population-based study by Aylin et al. published in the British Medical Journal suggests that patients undergoing surgery on Fridays and weekends have significantly higher of both 2-day perioperative mortality as well as 30-day mortality. Utilizing the robust information provided by the English National Health Service (NHS), the authors analyzed over 4 million elective cases performed in England from 2008-2011 and found a crude mortality rate of 6.7 per 1000 cases. While overall mortality seems low, after adjusting for confounding variables the authors found a stunning 44% and 82% statistically significant increase in 30-day mortality if an elective procedure was performed on a Friday or weekend compared to Monday, respectively. When analyzing 2-day mortality, the authors found a whopping 167% increase in mortality on a weekend compared with Monday.
A “weekend effect” has been proposed in prior studies, however these studies for the most part analyzed emergency admissions and included emergency surgeries on patients that were likely to be much sicker than the average patient. What makes this paper different, and thus more significant, is that it only analyzed elective procedures and is the first paper to suggest that with each successive weekday, patients are at increased risk of mortality, culminating with the highest risk on Fridays.
Data on urologic cases within this study remain unknown, as urologic procedures were not selected for sub-analysis. However, overall analysis included all elective procedures, which must have included high-risk urologic procedures such as cystectomy, nephrectomy, partial nephrectomy, prostatectomy, RPLND, and endourologic procedures on infected stones. Therefore, this data should still have relevance for urologists performing such high-risk procedures.
Why is this happening? We know that major complications from elective surgeries happen within the first 48 hours postoperatively (Cavaliere F, et al.). Therefore, patients that have surgery on Friday or over the weekend are at their most vulnerable when the hospital is most short staffed. Additionally, there has been concern that the more junior faculty and trainees bear the majority of weekend coverage, and are therefore most often the primary points of care over weekends, leading to potential failure to rescue due to inexperience. Finally, there is the issue of cross coverage and dialogue between hospital staff during the week and the weekends. How much can a covering physician truly learn about a potentially complicated patient from a simple sign-out?
More importantly, what can we do? Ideally, major cases should be scheduled earlier in the week to allow the patients to have care while all hospital staff are available during the remaining week or so of recovery. Endoscopic and same-day procedures should be scheduled later in the week. However, is this realistically possible? OR time can often come at a premium and is difficult to come by in some busy hospitals, especially for junior faculty. Therefore, such a change would have to come from the top hospital administrators and likely would meet resistance from more senior faculty.
When asked by The Guardian regarding these results, Sir Bruce Keogh, cardiac surgeon and director of the NHS, downplayed the results, stating that when he performed open heart surgeries he would often intentionally operate on patients later in the week to get more time in the ICU over the weekend. With all due respect to Sir Keogh, I just do not see the logic in this approach, and feel we should take these results more seriously rather than downplay them. The data presented by Aylin et al. seems pretty convincing to me: while overall mortality is low, patients getting surgery later in the week and on weekends are getting inferior care leading to inferior outcomes. We need to acknowledge this data, not ignore it or diminish it, and come up with some kind of reasonable and fair solution to the problem.
What say you, Urology community? If any field can come up with a solution, it’s us. Somehow, we need a system that allows all surgeons, young and old, to perform higher risk surgeries earlier in the week to prevent potential complications happening under the watch of an undermanned, inexperienced hospital staff over the weekend. In the meantime, I will try to use my free weekends for spending time with my wife, golf, and watching sports while trying my hardest to perform major surgery earlier in the week. Not only will this please my wife, it will likely improve the care of my patients.
Keith J. Kowalczyk, MD
Department of Urology, Medstar Georgetown University Hospital, Washington, DC, USA. @KeithKow
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