You’ve crashed your car on rural road at 2 a.m. on a rainy Saturday. Seriously injured and in pain, you are hauled into a noisy ambulance, then, because you’re so far from the nearest trauma center, into a waiting helicopter. You finally make it through the hospital doors just before 3 a.m. and are greeted by a team of able doctors and nurses wearing blue paper gowns and masks who descend on you like a swarm of bees. As you drift into a deep chemically induced sleep, you feel thankful that a well-organized, coordinated system was in place to save you in the middle of the night. And on a weekend, no less.
It turns out, however, that your confidence may not be so justified. For years, studies have shown that health outcomes — like recovery from heart attacks or procedures requiring time in intensive-care units — for patients who are rushed to emergency rooms at night or on weekends aren’t as good as for those who are treated during so-called working hours. But a recent study in the Archives of Surgery found that outcomes for injured patients in Pennsylvania are remarkably similar when comparing weekdays with weeknights, and that they are actually slightly better on weekends compared with weekdays. It was one of the first to demonstrate that for trauma, there is no “night-weekend effect” whatsoever, at least in Pennsylvania, which has a well-developed trauma system.
The reason for the effect is no mystery — smaller staffs with slightly less experience are more common during nonbusiness hours. On Monday afternoon, for example, hospitals are typically teeming with regular activities, so the add-on “emergency” heart attack can be squeezed in easily. But on Saturday night, there is a well-trained skeleton crew working the ER, but if coordination with other services is needed, groggy doctors summoned from home may have long drives to the hospital, delaying definitive treatment.
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So why are trauma patients like the ones in the Pennsylvania study different? The answer is smart system design and strict standards on the treatment of trauma patients. Trauma systems are planned so that patients are taken or quickly transferred to hospitals that specialize in treating serious injuries. And there are explicit criteria for designating such centers as, for example, a Level 1 trauma center that can handle sick, injured patients.
In more common types of emergencies, like stroke, patients can experience a wider range of care, depending on the type of hospital in which they find themselves. A study published this week documented a weekend effect in stroke patients in New Jersey hospitals: the chances of dying within 90 days of the stroke was 17.2% for patients admitted on weekends vs. 16.5% for patients admitted on weekdays — a small but statistically significant difference. But that weekend effect was limited to hospitals that were not comprehensive stroke centers and therefore not able to deliver a full spectrum of care to stroke patients.
Establishing such a full range of emergency care, however, comes with a high price tag. The use of CT scans for injured patients has more than doubled in the past decade. Indeed, trauma specialists tend to rely heavily on the results of expensive tests to make medical decisions, as do neurologists for strokes. Such costs are often prohibitive, explaining why the night-weekend effect continues to exist in most hospitals. For example, some hospitals can’t afford to keep their intensive-care doctors in the hospital around the clock, so patients who get sicker in the middle of the night often don’t have an intensive-care doctor who can immediately manage their care. Sometimes the ER doctor downstairs has to respond to internal hospital emergencies overnight, and many issues are managed by intensive-care doctors over the phone. In addition, maintaining a full staff of experienced health care workers on duty 24/7 doesn’t justify the reimbursement from the few patients trickling in who may need critical treatment off-hours.
On the other hand, there’s an argument in favor of both trauma centers and comprehensive stroke centers that transcends such economic concerns — studies show they save lives, the ultimate justification.
The solution? Many hospitals are working toward a happy medium to address both medical and economic needs by creating trauma-like networks for heart attacks and other critical-care needs. For stroke, they are developing programs that take advantage of telemedicine to increase the “comprehensiveness” of stroke care in rural communities where both specialized resources and personnel are scarce. Hospitals are also creating rapid-response teams that replicate the ER experience in which patients who are already admitted to the hospital can take advantage of a swarm of resources that is deployed to their bedside when they take a turn for the worse. This might help make up for lower staffing levels at night or on weekends. But the jury is still out: reports have not proved that these rapid-response teams save lives — yet.
The key is figuring out how to provide better night-weekend care for patients without dramatically increasing the costs of care. We are hopeful: with efforts to regionalize medical emergencies and efforts within hospitals, someday emergency care may be the same at 2 a.m. on a Saturday as it is at 2 p.m. on a Monday, regardless of whether you’re injured or having a stroke or some other medical emergency.
At least, you would be justified in feeling that way if you happened to have been injured in Pennsylvania.