Why business hours are bad for hospitals

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Original author: Vanda McNiven, Ngozi Iroanyah & Zeeshan Ansari

Published: March 23, 2020

Source: Healthydebate.ca

Sickness and accidents can strike at any time of the day or night. We are as likely to fall ill on a Saturday or Sunday as we are on a Monday or Thursday. So why do hospitals have fewer services available after regular business hours?

Only a skeleton crew is typically on duty in hospitals on evenings and weekends. Not only are fewer doctors physically present, but it can be hard to find a social worker, home care worker, imaging technician, physiotherapist, or even a spiritual counsellor.

“It really doesn’t make a lot of sense in this day and age, when everything else in the world is available seven days a week, that we cling to this old five-day model of care,” says Lauren Lapointe-Shaw, an internal medicine physician at the University Health Network in Toronto. This five-day “business hours” model means that patients are often kept in hospital over the weekend because they can’t be safely discharged due to lack of staff, inability to transfer patients to other facilities, or reduced diagnostic testing availability, notes Carl van Walraven, an internal medicine physician at The Ottawa Hospital. THE WEEKEND EFFECT

Several academic studies have confirmed a “weekend effect” on patient care – the observation of a significant increase in mortality when a patient is admitted to hospital on a weekend versus a weekday. These studies suggest that maintaining a more consistent level of service could be economical, even if staff members are paid higher wages on the weekend.

A 2019 review that analyzed 68 studies from around the world found that weekend admission was associated with a 16 per cent increase in the risk of death.

And a 2018 study of Ontario hospitals led by Lapointe-Shaw explored the similarly themed “holiday effect,” or “Christmas effect,” where staffing is decreased on holidays, much like on a weekend. The study found that patients discharged during the two-week December holiday period had a higher risk of dying within the next 30 days than those discharged in late November and January.

Fahad Razak, an internal medicine physician at St. Michael’s Hospital, says that data collected from seven Ontario hospitals through a research network called GEMINI suggests that there is a nearly 50 per cent drop in hospital discharges on weekends.

Discharges home can be delayed because tests like echocardiograms, endoscopies, and MRIs are more easily obtained on a weekday.

Beyond access to diagnostic tests, patients have limited access to physiotherapists and occupational therapists as well. These professionals, among other things, help ensure that a patient’s progress is not set back by a lack of exercise and movement. Elderly patients and those with restricted mobility can deteriorate over the weekend when they remain immobile in bed.

“We have a lot of patients who are at risk to deteriorate if they’re not getting up regularly,” says Andrea Gittens, a transitional care coordinator at the University Health Network. Any progress made during the week can be lost without access to an allied health professional (like a physiotherapist, occupational therapist, social worker, or speech-language pathologist), prolonging their stay.

And with each additional day that a patient spends in hospital, the costs can mount. The average cost of a standard hospital stay in Canada (7 days) was $6,137 in 2017-2018, excluding physician fees.

In a recent Globe and Mail article, Razak and his GEMINI co-principal investigator, Amol Verma, suggest that “providing normal hospital and post-hospital care on weekends and holidays may improve efficiency and better reflect the 24 hour, 7-day-a-week nature of human illness.”

The “business hours” model becomes an even more pressing issue during a pandemic. The current COVID-19 crisis has put a spotlight on how hospitals create capacity to cope with the potential surge of patients. Efficiently and safely moving people through the healthcare system is critical to free up bed space for people who are acutely ill and need urgent treatment.

“A significant number of patients probably don’t require hospitalization, but are in hospital because of other reasons, whether it’s waiting for long-term care or rehab,” says Razak. Approximately 14.8 per cent of Ontario hospital beds and 15.6 per cent of beds in Canada are occupied by patients waiting to be transferred to another facility.

And hospitalized patients are at an increased risk of getting hospital-acquired infections. This is an especially sobering concern with COVID-19, as hospitals can be a hotspot for the spread of infection. HOW THE BUSINESS HOURS MODEL CAN IMPACT THE EMERGENCY DEPARTMENT

One seeming exception to the “business hours” model is the emergency department (ED). Patients can come in at any hour of the day or night and, in fact, evenings and weekends are among the busiest times at most hospitals.

Emergency departments try to ensure that the ratio of nurses and doctors to patients remains constant 24/7, says Lucas Chartier, an emergency physician who works both at the University Health Network and North York General Hospital.  “168 out of 168 hours of every single week, the ED is the safety net for patients,” he says.

But ED staff face some of the same challenges in adapting to the shortage of after-hours staff elsewhere in their hospitals.

As per Chartier, the EDs of three big downtown hospitals share just one ultrasound technician between them after normal working hours. And most community hospitals have no technician on-site overnight.

Chartier observes that emergency patients often can’t get an ultrasound overnight “unless the patient is quite sick or may need to go to the operating room.” What’s more, fewer specialists and allied health professionals are on duty after-hours, if at all.

Less critically ill emergency patients either need to go home and return in the morning, or wait in the hospital overnight to complete their care plan. Given the shortage of rooms and beds in many hospitals, patients often have to wait on chairs in a waiting room or hallway. WHY HASN’T THE BUSINESS MODEL CHANGED?

A number of doctors and healthcare administrators acknowledge the inefficiencies of the “business hours” model of healthcare. It leaves us ill-equipped when patient volumes are high, like during a pandemic. And patients experience the drawbacks first-hand. So why does it continue?

Bureaucracy, resistance to change, and political election cycles all likely contribute to maintaining the 8 am to 5 pm, Monday to Friday status quo. “It would really take a systemic response to identify all the resources that we reduce on a weekend and to get a sense of what it would take to make those resources fully available on a Saturday and Sunday,” says Razak.

Financial constraints are clearly another hurdle, as expanding care would cost more in the short term. The Ontario Nurses’ Association Collective Agreement, as one example, stipulates that nurses are paid a premium of $2.80 more per hour on a weekend. Many of the allied health professions have unions or contracts that also ensure that they are paid more during weekends and holidays.

“A byproduct of this is that you hire fewer people,” notes Lapointe-Shaw. Healthcare workers with young children or other dependents, who don’t have a mechanism for them to be cared for, likely won’t want to work on a weekend either, says Razak. Internationally, Canada is under performing in providing after-hours care. In a health policy survey published in 2016 that surveyed physicians in 11 developed countries, Canada ranked among the lowest for ease of access to after-hours care without needing to go to the ER.

In contrast, the Netherlands ranked among the best. The Dutch use a model called the cooperative, or co-op, to provide access to after-hours care. Made up of groups of 50 to 250 providers, co-ops allow doctors to share the responsibility for after-hours care. Citizens need to purchase a basic insurance package and register with a primary care physician to access a co-op. Almost every Dutch primary care doctor participates in one, giving citizens 24/7 access to care that does not involve the emergency department.

In Canada, there has been some movement in the direction of a 24/7 model of care outside of emergency departments. For the past year, Toronto General Hospital has staffed one physiotherapist and one occupational therapist on weekends.  And the ratio of nurses to patients is almost the same every day of the week, notes Gittens.

“If we’re all in it together, and together we decide on a seven-day model,” says Lapointe-Shaw, “I think people would buy into that, because it makes sense from a patient care perspective.”

During this COVID-19 pandemic, freeing up beds for critically ill patients is crucial.  Hospitals are doing their best to discharge patients and leverage outpatient and virtual tools to manage them at home. But discharges continue to slow down on weekends and holidays. As Lapointe-Shaw points out, “there is a limit to how much efficiency you can squeeze out of an overstretched system.” Vanda McNiven is a freelance journalist pursuing a Certificate in Health Impact through the Dalla Lana School of Public Health and the Faculty of Medicine at the University of Toronto. She is also a senior resident physician at the University of Toronto.