Dr Foster Intelligence Variation in hospital services at weekends 1 2 3 4 Other papers Cavallazzi R, Marik PE, Hirani A, Pachinburavan M, Vasu TS, Leiby BE. Association between time of admission to the ICU and mortality: a systematic review and metaanalysis. Chest. 2010;138(1):68–75. Marco J, Barba R, Plaza S, Losa JE, Canora J, Zapatero A. Analysis of the mortality of patients admitted to internal medicine wards over the weekend. Am J Med Qual. 2010;25(4):312–318. Kuijsten HA, Brinkman S, Meynaar IA, et al. Hospital mortality is associated with ICU admission time. Intensive Care Med. 2010 Jun 15 (E pub ahead of print) PubMed PMID: 20549184. Dorn SD, Shah ND, Berg BP, Naessens JM. Effect of weekend hospital admission on gastrointestinal hemorrhage outcomes. Dig Dis Sci. 2010; 55(6):1658–1666. James MT, Wald R, Bell CM, et al. Weekend hospital admission, acute kidney injury, and mortality. J Am Soc Nephrol. 2010;21(5):845–851. Schilling PL, Campbell DA Jr., Englesbe MJ, Davis MM. A comparison of in-hospital mortality risk conferred by high hospital occupancy, differences in nurse staffing levels, weekend admission, and seasonal influenza. Med Care. 2010;48(3):224–232. Horwich TB, Hernandez AF, Liang L, et al.Get With Guidelines Steering Committee and Hospitals. Weekend hospital admission and discharge for heart failure: association with quality of care and clinical outcomes. Am Heart J. 2009;158(3):451–458. Shaheen AA, Kaplan GG, Myers RP. Weekend versus weekday admission and mortality from gastrointestinal hemorrhage caused by peptic ulcer disease. Clin Gastroenterol Hepatol. 2009;7(3):303– 310. Aujesky D, Jimenez D, Mor MK, Geng M, Fine MJ, Ibrahim SA. Weekend versus weekday admission and mortality after acute pulmonary embolism. Circulation. 2009;119(7):962–968. 5 Explanations • • • 6 Page 6 Patients • • Fewer discharges to alternative place of death People wait longer before seeking help / admission thresholds raised Staff • • • Fewer Less experienced More exhausted Available services • • Diagnostics Specialist interventions Hospital guide data • • • 7 Mortality rates weekend vs weekdays • HSMR • Emergency and Elective HSMR Measures of process • Time to operation • Number of discharges • Procedures performed Staffing levels • Medical staff on site and on call by grade at weekends and nights • Nurses and nurse assistants on care of the elderly wards at weekends and nights RTM v2 May 09 Proportion of total discharges which occur on a Saturday or Sunday <99.8% CL Within 99.8% CL >99.8% CL % of total discharges which occur on a Saturday or Sunday 25% 20% 15% 10% 5% 0% RA3 5QT RQ6 RGP RR7 RHQ RBZ RBA RVW RJR RDD RGR RVY RAJ RWJ RCB RTR RNQ RC9 RLT RW6 RXW RTX RCD RDE RV8 RYR Trust 8 RJE RWW RTG RNA RN7 RNZ RRV RD3 RPA RWA RJF RF4 RJ7 RHU RMC RWP RXQ RM1 RAS RC3 RA9 RNH Proportion of emergency spells with a discharge on a Saturday or Sunday <99.8% CL Within 99.8% CL >99.8% CL % of emergency spells with a discharge on a Saturday or Sunday 25% 20% 15% 10% 5% 0% RA3 RFF RJL REM RR7 RLN RDD RCC RC1 RL4 RXC RBD RVW RFS RXQ RBA RBZ RC9 RNL RA4 RGN RCF Trust 9 RJC RXL RTF RWJ RXP RTX RN7 RW6 RQ8 RR1 RXF RJZ RD7 RD3 RRV RVV RJ7 RM3 RAS RTH RXK RWA RBT RJN RNH RDU RRF 10 11 12 13 14 15 16 17 Staffing data • • • • • • 18 Page 18 Collected by questionnaire distributed to all acute NHS trusts Communication with assigned trust representative and confirmed with CEO Questionnaires distributed in June and completed by September Forms filled in online and data returned in printable format for validation and sign off Data returned for 190 acute hospitals 36 were unable to provide data on scheduled staff but could provide data on actual staff 19 RYJ03 RXK02 RRV03 RXPCP RWEAA RWH01 RGCKH RBK02 Senior staff call / 100 beds RJE02 Senior Staff site / 100 Beds RXQ50 RYQ30 RRF02 RVY01 RH801 RYR16 RJL32 20 0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 Senior staff call / 100 beds vs senior staff on site / 100 beds 14.00 12.00 10.00 8.00 Senior staff call / 100 beds Linear (Senior staff call / 100 beds) 6.00 y = 0.2128x + 2.4834 R² = 0.0232 4.00 2.00 0.00 0.00 21 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 Senior Staff per bed at weekend vs weekend HSMR 120.0 More Senior staff per bed 100.0 Weekend HSMR 80.0 60.0 40.0 20.0 0.0 Lower Quartile 22 Middle Upper quartile Senior staff as a % of all medical staff vs HSMR 120.0 More Senior staff per bed 100.0 Weekend HSMR 80.0 60.0 40.0 20.0 0.0 Lower Quartile 23 Middle Upper quartile Staff Grade Drs as a percentage of all Drs 120.0 More staff Grades on Duty 100.0 Weekend HSMR 80.0 60.0 40.0 20.0 0.0 Lower Quartile 24 Middle Upper quartile Some issues with staffing data • Staff grade doctors and registrars at non-teaching hospitals • Role of on-call doctors • • 25 Page 25 Is this a site or trust issue? The role of “satellite” A&E units – e.g. Princess Royal in Sussex – and public understanding of service provision Night staffing Comments and questions 26 Page 26