Hospital Dr News

Low staff levels not only reason for death rates

Low staffing levels are not the only reason why mortality rates increase in hospitals at weekends, two leading experts claim on bmj.com.

Andrew Goddard, director of the Medical Workforce Unit at the Royal College of Physicians, and Peter Lees, founding director of the Faculty of Medical Leadership and Management, suggest that a contributory factor is that patients admitted at the weekend are sicker than those admitted during the week.

A recent report by Dr Foster Intelligence grabbed the headlines by supporting the hypothesis that only early assessment and intervention by experienced clinicians will result in improved weekend mortality.

The report compared hospital standardised mortality ratios (HSMRs) for patients admitted to English hospital trusts on two weekends in April 2011 with those admitted in the week, and showed a clear association between reduced numbers of senior doctors in hospitals and increased mortality at the weekend.

However Goddard and Lees’ editorial, on bmj.com, says that hospital coding (on which HSMRs rely) is not sensitive enough to allow correction for the patients being sicker at weekends.

Although patients with certain conditions – such as trauma, alcohol associated conditions, and self harm – are more often admitted at the weekend, the main reason that sicker patients are admitted at the weekend is variation in referral practice, the editorial says. Out-of-hours primary healthcare services have changed dramatically over the past decade in the UK, with increasing reliance on “emergency medical services” rather than patients’ own GP.

Provision of hospital support services is also reduced at the weekend, it says, so fewer interventional procedures, such as percutaneous coronary intervention for acute coronary conditions and endoscopy for upper gastrointestinal bleeding, are performed.

The editorial does acknowledge that even when factors are considered, the observation of increased mortality and low staffing levels cannot be discounted and pose a serious problem for the NHS – with the process of increasing doctor numbers being slow and expensive.

Emerging data show that working patterns for consultants influence mortality, with hospitals in which the admitting consultants work blocks of more than one day have lower excess weekend mortality than those with a ‘physician of the day’ model. It also calls for research into which specialties could deliver the most benefit.

The number of medical registrars (who run most hospitals at night) could easily be the defining predictor of hospital mortality, it says, despite current plans to reduce their numbers.

“This may need to be re-thought but, given the potential profound impact on clinical outcomes, decisions must be based on sound evidence,” it says.

It also suggests the problem is more significant in hospitals in the north of England.

The editorial concludes that the Dr Foster report raises more questions than it answers and calls for greater insight into community out of hours services, hospital staffing, and workforce configuration. “All need to be reviewed against the knowledge of which conditions are associated with increased mortality at the weekend. This is an opportunity that, if tackled intelligently, will improve the care of some of our sickest patients for many years to come.”

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