by Richard Hughes & Claudio Bassetti
After the Christmas and New Year festivities, it is time to think of the standard of care we provide for our patients on holidays and at weekends. A day of rest, Friday, Saturday or Sunday, is built into the Muslim, Jewish and Christian week. The twentieth century, prompted by Henry Ford closing his factories on Saturdays and Sundays in 1926, expanded the one day of rest to two. Hours of work have been reduced to 40 or even less a week and the EU frowns on us working for more than 48, however much we want to. These days and hours have become the norm for the majority of the population. It is as if two days of rest a week are as necessary for health as 6-8 hours of sleep in every 24. However some sections of the community are expected to work at weekends. Shops are open and transport run services for those who have the leisure to use them. But disease does not rest. Strokes, fits, head injuries, meningitis and Guillain-Barré syndrome occur also on Saturdays and Sundays, occasionally even more often than during weekdays [1].
Bruce Keogh, the medical director of the English National Health Service, has issued a call to introduce more services at weekends and in particular to increase consultant availability then [2]. He does so because of evidence from several countries that weekend admission to hospitals is associated with a greater risk of death than weekday admission [3]. Freemantle et al. analysed all admissions to National Health Service Hospitals in England for one year in 2009-10 and followed up all patients for 30 days after admission. This gave a huge sample of 14,217,640 admissions and 187,337 deaths. The risk of subsequent death was significantly greater for admissions at weekends. Even after allowance for a variety of baseline risk factors, the hazard ratio for a Sunday admission was 1.16 times greater than for a Wednesday admission (95% CI 1.14 to 1.18; P< 0.0001). The figures for Saturday were similar. Similar observations have been made in US managed care hospitals [3] and in patients with stroke [4]. While the results might be explained by a variety of factors including alcohol/drug consumption, altered sleep patterns and differences in case mix between weekday and weekend admissions, data suggest that weekend care is less safe. It is certainly a matter of common observation in many hospitals that the weekend creates a major hiatus in the progress of investigations. It behoves us all to examine our arrangements for holiday and weekend care. Consultants need rest too so that universal 24 hour consultant neurologist cover needs good planning, adequate staffing and intelligent use of telemedicine. Neurology is the most clinical of specialties and the consultant clinical opinion is usually more important than any investigation and never more useful than in an emergency. The EAN should aim to encourage continuous high quality acute neurological care across Europe.
Claudio Bassetti & Richard Hughes
1. Puljula J, Savola A, Tuomivaara V, al. e. Weekday distribution of head traumas in patients admitted to the emergency department of a city hospital: effects of age, gender and drinking pattern. Alcohol 2007;42:474-479.
2. Keogh B. Should the NHS work at weekends as it does in the week? Yes. Brit Med J 2013;346:f621.
3. Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shahian D, Roche WR, Stephens I, Keogh B, Pagano D. Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 2012;105:74-84.
