Skip to Main Content
Skip Nav Destination

Report addresses off-hours care variances in neurosurgery patients :

July 29, 2016

Dr. JeaDr. JeaVarious studies have shown that 30-day morbidity and mortality risk is higher among both pediatric and adult patients who are admitted on the weekends. This “weekend effect” has been observed among patients for a broad spectrum of diagnoses and procedures, including myocardial infarction, pulmonary embolism, ruptured abdominal aortic aneurysm, stroke, peptic ulcer disease and pediatric surgery.

A recent study has shown the weekend effect also affects pediatric patients undergoing neurosurgical procedures (Desai V, et al. J Neurosurg Pediatr. 2015;16:726-731).

As part of a quality improvement initiative, the authors compared morbidity and mortality for urgent and emergency pediatric neurosurgical procedures performed at Texas Children’s Hospital on weekends or after hours with procedures performed during regular weekday hours. A total of 710 procedures were performed between Dec. 1, 2011, and Aug. 20, 2014, in children younger than 18 years of age.

Patients were stratified into three groups based on when their surgery was performed: weekday regular hours, weekday after hours and weekend. Each patient was cross-referenced with a prospectively collected morbidity and mortality database for the occurrence of complications. Patient-, procedure- and system-related risk factors were analyzed using logistic regression models.

The weekday regular-hours and after-hours surgery groups combined included 341 and 239 patients, and 434 and 276 procedures, respectively. There were no differences in the types of cases (cerebrospinal fluid diversion procedure vs. other) or the baseline pre-operative health status as determined by American Society of Anesthesiologists classifications (p = 0.220) between patients operated on during regular hours or after hours.

After multivariate regression, pediatric neurosurgical procedures performed on weekdays after hours and on weekends were associated with increased 30-day morbidity and mortality risk compared to procedures performed during weekday regular hours (p = 0.0227).

Among the reasons for the weekend effect are staffing deficiencies, resident work-hour restrictions, shift work and hand-offs in neurosurgery. A skeleton crew of physicians and nurses are in-house during these times, with an associated increase in individual workload. In addition, physicians who work after hours and on the weekends may be less experienced than those available during regular hours, and they often cover patients and disease processes with which they are less familiar (Petersen LA, et al. Ann Intern Med. 1994;121:866-872; Thorpe KE. JAMA. 1990;263:3177-3181; Freed GL, et al. Pediatrics. 2012;130:700-704).

Some hospitals have tried to rectify this deficiency by increasing the number of hospitalists to furnish uninterrupted coverage of patients (Freed GL, et al. Pediatrics. 2012;130:700-704) and training a corps of advanced practice providers to afford continuity of care.

Lack of experience is not unique to surgeons and physicians. Operating room nurses on duty after hours often have less skill and knowledge of pediatric neurosurgical procedures than their counterparts who usually are members of the neurosurgical team during regular hours.

After-hours operating room staff typically is drawn from a general on-call pool; these nurses and scrub technicians frequently are cross-trained to cover a spectrum of surgical specialties. Few, if any, attain proficiency in any one surgical specialty such as neurosurgery. Cross-training operating ancillary staff may increase flexibility for call coverage and may be more cost-effective than training in a single surgical specialty, but it may be a contributor to poorer patient outcomes in neurosurgical procedures performed after hours and on weekends.

A possible solution is that specialized pediatric neurosurgical teams should cover the operating rooms not only during regular hours but also after hours. There is a call for the development of microsystems in the operating room. Neurosurgical on-call operating room teams must include surgeons and, perhaps more importantly, neurosurgical operating room nurses and scrub technicians; these teams should manage all acute neurosurgical patients.

Finally, when patients are referred to these tertiary and quaternary medical centers, they should undergo protocol-driven perioperative care (Crowley RW, et al. J Neurosurg. 2009;111:60-66) i.e., ensuring the same standardized care regardless of the day of the week or time of day.

In an effort to address off-hours care variances, the authors made the following recommendations: ensure that care is protocol-driven; form on-call neurosurgery operating room teams; and increase the number of hospitalists and advanced practice providers.

Dr. Jea is a member of the AAP Section on Neurological Surgery Executive Committee.

Close Modal

or Create an Account

Close Modal
Close Modal