The Weekend Effect and Hospitals

If you walk into a mom-and-pop convenience store on a weekend, you may find that the service is slow. Weekends are downtimes for many businesses, and lots of retail stores are understaffed during lower-traffic periods like weekends, nights and holidays.

However, you may be surprised to learn that understaffing and diminished service during downtimes are experienced in hospitals, too. This phenomenon, called the Weekend Effect, is linked to increased death among patients admitted to the hospital. The Weekend Effect has also been linked to other serious repercussions, such as bleeding and infection.

Apparently, the Weekend Effect postpones time to life-saving treatment, and with emergency presentations in a hospital setting, a difference of a few minutes can be critical. This phenomenon may also be tied to a paucity of investigative (diagnostic) services available during the weekend as well as reduced access to specialized physicians, who are often “on-call” and not physically present in the hospitals on weekends.

Although the Weekend Effect has been documented in other countries — particularly in the United Kingdom where it has raised great concern — it has only been recently documented in the United States. Furthermore, although there are studies that fail to support its validity, a rapidly growing body of evidence seems to conclusively point to this phenomenon.

Let’s first take a look at some examples of the Weekend Effect as evidenced in the literature. Then, we’ll examine the greater significance of this phenomenon.

Weekend Effect and Stroke

With improvements in care, more people who experience strokes survive. Nevertheless, in a landmark 2015 study published in PLoS ONE, researchers found that the Weekend Effect is alive and well in the United Kingdom.

In this retrospective study, researchers examined mortality (i.e., death) among 37,888 people who were treated for stroke in a hospital setting between 2004 and 2012. When compared with weekday admissions to manage stroke, mortality at seven days following a weekend admission was 19 percent higher—even though there were 21 percent fewer admissions! Analyses of the data were adjusted for age, sex and 11 co-morbidities, or other chronic conditions, including malignancies, other circulatory disease problems, diabetes, and dementia.

Of note, in this study, mortality was lowest in the hospital with a dedicated stroke unit. Furthermore, mortality was higher for strokes with an unspecified cause than it was for cerebral infarction, wherein a blood clot interferes with blood flow to the brain.

The researchers also examined the effect of three other factors on stroke mortality: admissions during winter months, community versus large hospital admissions and greater distance between patient residence and the hospital itself (more than 20 kilometers). Although their findings were not statistically significant with respect to the influence of these other variables on mortality rates, the researchers suggest that these other three factors may still somehow play a role in the likelihood of patient survival after stroke.

The Weekend Effect has also been observed with respect to stroke mortality in the United States. In a research letter titled “’ Weekend Effect’ or ‘Saturday Effect’? An Analysis of Hospital Mortality for Patients With Ischemic Stroke in South Carolina,” researchers examined all acute ischemic stroke hospitalizations (20,187 cases) in South Carolina between 2012 and 2013. The researchers assessed the frequency of death in patients admitted for stroke according to the day of admission, and these crude mortality measures were adjusted for patient sex, age, race, year of admission, the season of admission, payer type, and Charlson Comorbidity Index (a measure that incorporates various other chronic conditions). Among this South Carolina patient population, stroke mortality was highest on Saturdays thus pinpointing the weekend effect to a specific day.

On a related note, results from this U.S. study suggest that stroke severity was greater during the weekends thus indicating a higher threshold for admission; patients admitted for stroke during the weekend were typically sicker than those admitted during the weekdays. This finding could confound results and explain some of the differences in mortality. In other words, because patients with stroke who were admitted over the weekend were sicker, they could be at increased risk of death.

Weekend Effect and Pediatric Surgery

In a 2014 study published in the Journal of Pediatrics, researchers from The Johns Hopkins University looked for the Weekend Effect among 439,457 U.S. pediatric surgeries that were performed between 1988 and 2010. These surgeries included abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation (ORIF), placement of a surgical shunt, or revision of a surgical shunt.

The researchers found that mortality was higher among children who had weekend surgeries than it was among children who had weekday surgeries. Furthermore, children who received surgeries during the weekend were at higher risk for blood loss and blood transfusion, wound infections, wound rupture (wound dehiscence) and other adverse effects. As with other studies examining the Weekend Effect, these findings presented independently of other patient and hospital characteristics.

It should be noted that death secondary to pediatric surgery is rare in the United States and other developed countries. However, the results of this study do have clinical relevance because the Weekend Effect is still linked to a small number of deaths, and the preventable death of even one child is a profound loss to her family, friends, and community.

Weekend Effect and the Emergency Department

During weekends and other downtimes, the emergency department is the place where most hospitalized patients get admitted. In a 2013 study titled “Don't Get Sick on the Weekend: An Evaluation of the Weekend Effect on Mortality for Patients Visiting U.S. EDs,” researchers from the University of Michigan looked for evidence of the Weekend Effect among patients admitted to the hospital via the emergency department.

In this retrospective study, 4,225,973 cases representing 20 percent of the total admissions occurring by way of the emergency department during 2008 were analyzed. The Weekend Effect was observed in this sample, and more people who were admitted during the weekend died than those admitted on weekdays. This effect was consistently observed regardless of patient income, insurance status, hospital ownership (public or private), hospital teaching status and emergency room census. Moreover, the Weekend Effect was consistently evidenced among the top 10 most common diagnoses, such as stroke, heart attack, malignancy, and head injury, indicating that this phenomenon wasn’t specific to any one diagnosis.

What We Don’t Know

Although reduced weekend staffing is considered a general explanation for the Weekend Effect, we aren’t sure the exact causes of this phenomenon. For example, we don’t know whether these staffing issues pertain to nurses, specialists, physicians or some combination. We also don’t know whether increased hospital occupancy and overburden during the weekend played a role. Importantly, weekend shift changes during which care is transitioned may also contribute to this phenomenon.

Ultimately, the studies that currently examine the Weekend Effect are limited by their retrospective (not randomized-control) design, and further research needs to be done to suggest more concrete solutions. In the meantime, it’s probably a bad idea to indiscriminately cut or deny funding that affects staffing to hospitals.

What Does All This Mean?

Let’s consider what the Weekend Effect means to individuals. In the studies cited, this phenomenon was observed among people being admitted to the hospital for acute and emergent presentations. Because these were emergency problems, the patients had no control over the time of the presentation and couldn’t choose whether to enter the hospital on a weekday or weekend.

Similarly, if you or a loved one experiences a medical emergency, admission needs to be swift regardless of the day. In other words, a heart attack that occurs on Saturday can’t wait for a Monday admission. Furthermore, please take heart that despite worries about the Weekend Effect, care provided by the vast majority of U.S. hospitals is good and follows strict clinical guidelines — preventable deaths are rare even on the weekends.

Instead of pertaining to the individual, the results of these studies hint at a greater issue faced by clinicians, administrators, advocates, and policymakers: how to reduce unnecessary deaths linked to discrepancies in the care provided during weekends and other downtimes. With the costs of health care burgeoning, there’s a lot of talk about cutting funding. However, we must ignore the rhetoric and gingerly consider cuts that affect staffing or quality of care in healthcare settings.

If a hospital is operating on the weekends, the services must be up to snuff. Hospitals can’t be cheap when it comes to resources and staffing. Furthermore, when shifts change and patient care is transferred, there should be no deprecation in services attributable to these transitions. Ultimately, if a hospital can’t provide the same quality of care during a weekend and a weekday, it’s questionable whether it should be providing weekend care at all. Specifically, studies have suggested that 24/7 access to specialized stroke centers, trauma systems, and pediatric intensive care units — settings in which access and staff availability are always consistent — have all demonstrated the ability to do away with the Weekend Effect.

The next time you hear a politician talking about cuts to healthcare, please consider that these cuts can translate into consequences that affect us all, like the Weekend Effect. The hospital isn’t a mom-and-pop convenience store where you can wait a bit longer for a cup of coffee or pack of peanuts without concerns for your health. A hospital is a place where time and resource availability are crucial and minutes count.