|Towards a single standard 7 days-a-week|
|Thursday, 29 August 2013|
In May, an article in the BMJ on the association between mortality and the day of elective surgical procedures gave fresh impetus to the debate on seven-day care. Here, three contributors discuss the challenges and potential solutions to providing the same standard of care, regardless of the day of the week. Alastair Murray begins with why the case can now be made for sensible scheduling of risky surgery
It is not unusual for some of us to experience a little anxiety whilst waiting for our plane to take off. Many of us distract ourselves from considering the improbable laws of physics on which it all depends by reading the newspaper. Would it be discomforting to read in the paper at that moment that the day you have chosen to fly turns out to have the statistically highest chance of the plane crashing? You would be laid back indeed if it did not at least give you pause for thought. Similar emotions must now be familiar to those awaiting their operation on a weekend and they require our sympathy.
Patients are obviously entitled to expect rather more than our sympathy in response to the apparent dangers of weekend operating. A recent study in the BMJ of more than 4 million elective operations in England between 2008 and 2011 suggested an 80% increased risk of death from weekend surgery compared with surgery on a Monday. This is not the sort of statistic that helps patients rationalise their natural anxieties prior to an operation.
It has been recognised for some time that out-of-hours care can be riskier. CEPOD identified this many years ago and changes to surgical practice as a result have definitely saved lives. Aylin’s findings no doubt raise concerns that must be addressed but we must do so rationally. Neither this study nor any of the previous authors of similar publications have been able to identify all the reasons for poorer results at weekends.
The assumption that it is due to poorer staffing levels is just that; an assumption. Perhaps this is not unreasonable but neither is it a good basis to demand wholesale costly changes to how hospitals run until the issue is looked at in more detail. If chief executives wish to respond to media and political pressure by proposing a comprehensive seven-day week service that is fine, but the taxpayer needs to have a fairly high degree of certainty that the expense is merited and that results will improve.
The study in the BMJ deserves close scrutiny. It found that the overall mortality rate for all planned surgery at weekends was 0.74% compared with 0.55% on a Monday. This is certainly a matter of concern but what is acknowledged by the authors is that this is a reflection of a rising mortality throughout the week, not just a weekend effect. Put rationally, the safest day to have an operation is Monday. It’s riskier on a Tuesday and slightly worse still as the week progresses. Instead of blaming poor weekend service provision perhaps we should be looking at why Mondays are the safest day? Was it of any significance that Monday consistently had the lowest volume of surgery of any of the week days? The study also showed no day of the week effect on mortality for minor ‘low risk surgery’, which included joint arthroplasty, hernia repair, tonsillectomy and similar procedures. This represents the vast majority of weekend elective surgery and is a reassurance that we should convey to patients undergoing this type of treatment.
It seemed incontrovertible however that major, lower GI surgery had a worse mortality rate at the weekend. Of the specialty groups of major surgery specifically considered, this stood out as perhaps the riskiest. Does this mean that this particular group of patients should not have this kind of surgery at the weekend? It certainly suggests that lower GI surgeons and managers should look at this in detail and try to identify the reasons.
Not all major surgery, however, carried greater risk at the weekend. Major upper GI surgery had the highest mortality if performed on a Thursday. Perhaps this is because the first 24-48 hours are spent in critical care and problems arise 48 hours later but does it mean that it is actually safer to have your oesphagectomy on a Saturday so that you enter the riskiest post-operative period a day or two later when ward staffing levels are optimal? I am not an upper GI surgeon and cannot claim to have insight into the detail. This is simply proposed to provoke discussion.
We owe a debt of gratitude to the studies which have looked at the outcomes from elective surgery on such a scale. They have shone a light on the potential impact of the scheduling of elective procedures. Surgeons, anaesthetists and managers must look at these figures and take into consideration when certain cases are being performed. This goes against historical practise that it is pure chance when a surgeon has an elective list. Indeed, might this mean that at least the newest consultant is not given the Friday operating list? While staffing hospitals to provide full elective services seven days-a-week remains unaffordable is it perhaps more achievable to schedule major, planned surgery for the best possible day of the week within existing resources and perform the lower risk cases at the end of the week or over the weekend?
Patients deserve our reassurance that the majority of surgery is just as safe at weekends as any other day. For major surgery, they should be able to feel that we have considered and optimised their post-operative course: that we have not accepted that their surgery is being carried out on a suboptimal day. Many surgeons already strive to do just this but often meet resistance from service demands led by non-clinical staff. Aylin has now provided us with evidence to make our case for sensible scheduling of risky surgery. We should be grateful for that.
As for which day is the riskiest to fly: I will leave that unsaid in case you are reading this on the plane. Interestingly though, it turns out that the day of the week is far less of a risk factor than your choice of airline. Perhaps that is where we should leave the analogy for now?
Consultant Orthopaedic Surgeon, RHSC, Edinburgh