Choose what day you have your heart attack carefully, if you want to survive. By Dr Raj Persaud

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CHOOSE WHAT DAY YOU HAVE YOUR HEART ATTACK CAREFULLY, IF YOU WANT TO SURVIVE…

DR RAJ PERSAUD CONSULTANT PSYCHIATRIST

DSCF0304The media has recently been explaining to me that Hospital Consultants need to work weekends. Or should that be more weekends? This is in order to cut a recently highlighted ‘spike’ in deaths which seems to cluster at the end of the working week.

Dr Mark Porter, the British Medical Association’s Consultants Chairman, apparently quoted the example of University Hospitals Coventry and Warwickshire recently commencing 12-hour working shifts for Consultant Anaesthetists on Saturdays and Sundays.

Everyone’s been wondering aloud and considering some ‘blue sky thinking’ about hospital doctors’ weekends following the end of last year, when research organisation Dr Foster reported mortality rates rose by 10% at weekends.

NHS medical director Sir Bruce Keogh is reported as adding: “Having more senior staff and consultants around at weekends is fundamental to the NHS shifting from a five-day-week to a seven-day-week”.

I was at first astonished; that anyone in the NHS might acknowledge that the expertise of doctors might make a difference to a patient’s outcome. Me never having encountered this take on healthcare during my 16 years as a Consultant in the NHS. It seems like having ignored your opinion all day during the week, the managers want you back at the week-end – all is forgiven. So, the data might be a good way of reminding the NHS mandarins of the obvious – doctors make a difference.

But, if we’re not careful, this story is going to spin out of control, and doctors are going to end up catching the blame for another lumbering inefficiency linked to mismanagement.

While there are many who are keen to let doctors shoulder the blame for any healthcare problem, the reality is, given fewer people work in hospitals on weekends, all across the board, not just at Consultant level, there is less access to resources such as radiology and laboratory, all across the board. There is little point filling the hospitals with specialists if the kinds of services these specialists are going to require to do their job, remain at skeleton levels.

So basically if there are more Consultants there are going to have to be more of everyone else as well, otherwise senior doctors just end up being a convenient scapegoat. And this all means massively increased costs, at precisely a time I was given to believe swingeing cuts are being implemented. The only way to square this circle is to… blame the seniors for hiding on their golf courses at week-ends.

It’s worth noting that this week-end death rate effect is a worldwide phenomenon; a 2006 study published in the European Journal of Internal Medicine of 35,000 consecutive emergency hospitalizations of adult patients in Fundacio´n Hospital Alcorco´ n, Madrid, over a 5-year period, found admissions via the emergency department on weekends had a very significantly increased risk of dying

within the first 48 hours when compared with patients admitted on weekdays.

The problem acknowledged by those who have taken an interest in the ‘weekend mortality effect’ is that patients admitted to hospital at this time are also different than those admitted at other times, and this contrast could be responsible for some of the effect. They are often sicker. Or they could simply be a contrasting case mix.

We already know there’s a strong weekly pattern of acute Heart Failure admissions. Monday, for example, is a critical day for excess occurrence of cardiovascular events, e.g., Acute Myocardial Infarction, sudden death, stroke, and transient ischemic attacks, with the stress of going back to work usually blamed. At least if doctors are working all the time, they won’t notice this ‘back to work’ stress effect of Mondays. Perhaps they’ll get their Heart Attacks on Fridays, as the prospect of another working week-end looms.DSCF0093

We know the Monday heart attack effect is something to do with stress of work, because there’s a marked increase in the number of Acute Myocardial Infarction cases on the first workday following Monday public holidays i.e. on Tuesdays. It’s also no mere chance coincidence that suicides also peak on Mondays.

This all goes to show that patterns of presentation of contrasting diseases, given strong weekly cycles that already exist, need to be taken account of before conclusions are drawn that outcomes are purely down to the doctors.

In another big study of all adults admitted to Intensive Care Units in the Calgary Health Region, Alberta, Canada, during 2000 to 2006, the precise day of admission made a significant difference, not just week-ends, with the best day for your eventual prognosis to get admitted being, mysteriously a Thursday. The authors of this study published in the Journal of Critical Care were not so bothered by a week-end effect, but instead noted a much more important day/night effect, with both being admitted to and discharged from an ICU after hours significantly negatively effecting your mortality.

A lot of research in this area has focused on night/day differences, which the debate in the media has been silent on. For example, in a study of 730 cardiac arrests at a large tertiary care hospital, patients who arrested during office hours (8:00 am–4:30 pm) boasted survival rates double that of those arresting during non-office hours. It was cumulative data like this which lead to the authors of a paper just published in the Journal of Emergency Medicine to institute a cardiac arrest team plan which eliminated this week-end effect. Notably the authors point to the senior physician lead nature of the solution.

So if the data was really driving this issue – we would be contemplating a 24 hour NHS with no respite day or night – a bit like a 24 hour Tesco’s. But any solution must look at the medical research into the subject because the weekend effect applies to some disorders and some treatments but by no means all. Debate rages in the literature because while some find a weekend effect, others don’t, because they say the different case mix at weekends, and other confounding variables are not being properly taken account of.

Given the elderly make up a large part of the mortality, some authors have wondered if the presentation at weekends of different kinds of cases has something to do with younger relatives unable to get their elderly relations to the doctor during the week, due to work commitments. This leaves weekends as the only time working relatives can assist with bringing about medical attendance.

In another very big study (N=641,860) published in the American Journal of Medicine comparing mortality rates between patients admitted on weekends and weekdays admitted to teaching and non-teaching hospitals in California, the  magnitude of the weekend effect in major teaching hospitals was unexpectedly larger than in nonteaching hospitals. US Teaching Hospitals boast relatively constant levels of staffing provided by excess residents and fellows available at week-ends. The authors conclude that in retrospect, their hypothesis was overly simplistic; ‘the weekend effect reflects more than physician availability on weekends,’ they conclude.

Tell that to the media and the BMA.

It’s what the authors of this research refer to as a ‘confluence of factors’ that ultimately result in the notorious weekend effect.

What would be really interesting, given the complexity of the subject, is to find data that demonstrates whether the weekend effect is getting worse in the UK NHS over years, or getting better. You would have to be excused a sneaking suspicion that it might be worsening given all the recent publicity.

Because the elephant in the living room, as it were, is, if it’s getting worse, it tells us something about a possible widening gap (some would say chasm) in training between more junior and senior grades in the profession. This might mean when there are less senior staff around or they are less accessible, the fissure in training becomes more exposed.

This possibly widening abyss been brought about by a series of attacks on the training of doctors that have taken us away from the team spirit and apprentice model of the traditional medical firm. Many senior doctors believe a cascade of these ‘reforms’ have conspired to dramatically worsen the quality of modern junior doctor preparation.

Is it possible no better proof of this would be if the weekend or out of hours effect has spiralled into worse proportions since training has been reformed?

Why are the authorities so silent on this possibility?

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REFERENCES

 

Hospital mortality among adults admitted to and discharged from intensive care on weekends and evenings Journal of Critical Care, Volume 23, Issue 3, September 2008, Pages 317-324 Kevin B. Laupland, Reza Shahpori, Andrew W. Kirkpatrick, H. Thomas Stelfox

 

Effects of weekend admission and hospital teaching status on in-hospital mortality The American Journal of Medicine, Volume 117, Issue 3, 1 August 2004, Pages 151-157 Peter Cram, Stephen L Hillis, Mitchell Barnett, Gary E Rosenthal

Mortality among adult patients admitted to the hospital on weekends European Journal of Internal Medicine, Volume 17, Issue 5, August 2006, Pages 322-324
R. Barba, J.E. Losa, M. Velasco, C. Guijarro, G. García de Casasola, A. Zapatero

Weekend versus weekday acute hospital admissions for heart failure
International Journal of Cardiology, Volume 148, Issue 1, 1 April 2011, Page 119
Massimo Gallerani, Benedetta Boari, Fabio Manfredini, Elisa Mari, Cinzia Maraldi, Roberto Manfredini

 

Permanent stress may be the trigger of an acute myocardial infarction on the first work-day of the week International Journal of Cardiology, Volume 144, Issue 3, 29 October 2010, Pages 423-425 Jozsef Bodis, Imre Boncz, Ildiko Kriszbacher

 

The monthly and weekly distribution of suicide Social Science & Medicine, Volume 21, Issue 4, 1985, Pages 433-441 Walter Massing, Matthias C. Angermeyer

 

A Standardized Code Blue Team Eliminates Variable Survival from In-hospital Cardiac Arrest The Journal of Emergency Medicine, Volume 42, Issue 1, January 2012, Pages 74-78 Sultana A. Qureshi, Terence Ahern, Ryan O’Shea, Lorien Hatch, Sean O. Henderson

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