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Breaking News: The 24/7 ED in the 9-5 Hospital

Shaw, Gina

doi: 10.1097/01.EEM.0000406940.89478.3b
Breaking News

If you absolutely must have an accident that requires you to be rushed to the emergency department, whatever you do, don't do it on a Monday.

Why not? Because at virtually every hospital, surgeons and other physicians who are booking elective admissions want to schedule their procedures for the beginning of the week, which means that on Mondays, hospital beds are in short supply.

“Most people want to get their cases done early on in the week, so that other resources, like physical therapy, will be available for their patients during the latter half of the week,” said Peter Viccellio, MD, the vice chairman and the clinical director of emergency medicine at Stony Brook (NY) University Medical Center.

That's because although hospitals technically never close, in reality, substantial chunks of every hospital are set up to operate as if they were on bankers' hours. Elective surgeries, elective imaging, physical and occupational therapy, and many other types of non-emergent care simply are not done after 5 p.m., not during the week and certainly not on weekends.

“Mondays in most emergency departments are just impossible — and predictably so — because no one's been around on the weekends,” Dr. Viccellio said. “Not only do physicians bring in their elective admissions on Sunday evening and Monday morning, we have half the number of discharges on weekends as we have on weekdays. You load up and overwhelm the system, and there are no beds available. This happens every Monday in every hospital.”

The consequences of this 9-5, Monday-Friday approach to inpatient care are more than simple crowding in the ED. They can literally be deadly for patients. “All sorts of consequences have been documented in terms of increased morbidity and mortality,” Dr. Viccellio said. “Everything that you can measure related to this is bad.”

ED crowding is only one consequence of the imbalance. This gridlock manifests as increased ED diversion and boarding, poor patient outcomes, and delayed transfers, said John Goodman in his health policy blog for the National Center for Policy Analysis, a Dallas think tank where he is the president and founder. (http://bit.ly/GoodmanBlog.) Studies have found that patients who are admitted to the hospital over the weekend have an increased risk of morbidity and mortality because of the understaffing and underservicing during those hours. One study found significantly higher mortality for nonelective admissions on weekends in 15 of 26 major diagnostic categories. (Arch Surg 2011;146[5]:545.)

So you shouldn't have the kind of accident that gets you sent to the ED — and then admitted to the hospital — on a weekend either. Or on a Thursday night because doctors are admitting more elective patients, such as women having scheduled C-sections, to get their procedures completed before 5 p.m. on Friday. So it looks like Tuesday and Wednesday might be the only reasonable days to have an accident.

“This is an artificial design that's killing patients,” says Eugene Litvak, PhD, the president and CEO of the Institute for Healthcare Optimization, an organization focused on bringing the science and practice of operations management to health care delivery. “It's clear that when you have peaks and valleys like this, you put the hospital under stress. When you have a peak in patient demand that exceeds hospital capacity, your resources are stretched to the breaking point. Then you have a patient demand valley, and there is simply waste. We kill people needlessly with these artificial two-day valleys in services when patient need exceeds hospital ability to take care of them.”

Excess morbidity and mortality might be the worst consequence of leaving hospitals understaffed and underserviced on weekends, but it's far from the only one. In a May post on the Health Affairs blog, Dr. Litvak's colleagues Michael Long, MD, and Sandeep Green Vaswani, MBA, explained, “Chemotherapeutic protocols may be interrupted, post-surgical rehabilitation prolonged, and medical diagnosis delayed because key physicians or services are not available.” (http://bit.ly/LongBlog.)

But the effects stretch into the week as well, they wrote. “It is increasingly well appreciated that hospital quality of care on weekends is compromised; it is less widely appreciated that restricting services over weekends also reduces the ability of hospitals to deliver quality care during the regular five weekdays.”

All of this is costing the health care system money, to the tune of billions of dollars, Dr. Litvak argued. He pointed out that U.S. hospitals on average are only about 66 percent occupied, and yet many hospitals are constantly seeking to add capacity for their overstretched weekdays by building new beds. “One new bed in a hospital equals over a million in capital costs and over a quarter million in annual costs. And yet, we keep building those beds.”

Dr. Viccellio's institution is slowly beginning to add more services on weekends, he said. “It surprised me how many discussions you have to have to realize that physical therapy is needed on the weekend. I take off on the weekend, but a patient's hip recovery doesn't. But still, we haven't added elective surgical procedures to our weekend schedule.”

One institution that has is NYU Langone Medical Center in New York City. Under the direction of Richard Grossman, MD, a professor of radiology who became dean of the medical school in 2007, the hospital last year began a move toward becoming a 24/7 facility. In addition to a wide range of non-emergency imaging procedures and cardiac catheterization services, Langone now offers scheduled Cesarean section surgeries as well as some cardiothoracic operations and orthopedic procedures on Saturdays and Sundays.

“This vision makes an immense difference to our patients and to the functioning of the emergency department,” said Lewis Goldfrank, MD, the chair of Langone's emergency department. Since the hospital began phasing in 24/7 services, another New York hospital, St. Vincent's, closed its doors. “Had these changes not occurred, the additional patient load coming to our ED would have been much more debilitating. It has begun to assist in smoothing out the entry to the hospital. People are getting in for services when they need them, as opposed to focusing on a restrictive 40-hour window.”

Hospital administrators can't argue with the numbers, Dr. Litvak said, but few have Dr. Grossman's commitment. “It's like cutting through sour cream — there's no resistance and no slice,” he said. “They can't dispute what we're saying because it's supported by data, and yet they just don't want to do it. People don't want to work weekends, they say. But what are we going to pay for this reluctance to work on weekends? The toll is pretty high.”

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The 24/7 Hospital

Read Dr. Viccellio's editorial, “Queueless or Clueless? Why Inpatient Services Should be 24/7,” and Dr. Leap's column, “‘It's the Same Everywhere' and Other Indefensible Excuses” for more views on the 24/7 hospital — only on www.EM-News.com.

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