On Patient Safety: The Weekend Effect

The “weekend effect” refers to the persistent finding that patients who are hospitalized or undergo surgical procedures on Fridays or over the weekend are more likely to experience complications, readmissions, and poorer health outcomes. An increased risk of death for weekend admissions has been documented for a variety of conditions, ranging from pulmonary embolism to childbirth [3, 5, 15]. Patient-centered outcomes are worse as well, with higher complication rates, costs, and longer wait times for tests and procedures [13]. Elective orthopaedic procedures appear to be particularly vulnerable, with higher rates of readmissions, complications, and deaths for weekend patients being demonstrated in studies from Canada [7], the United Kingdom (UK) [1], and the United States (US) [14], to name a few. In one of those studies [7], orthopaedic surgery showed some of the greatest weekend effects among surgical specialties, second only to cardiothoracic surgery.

These findings point to the urgent need to improve our weekend patients’ safety. Causes for the weekend effect are multifactorial and debated, but I believe orthopaedic surgeons can ameliorate its impact by changing our operative schedules, increasing our engagement on weekend rounds, and pushing for adequate clinical staffing.

On weekends, hospitals generally operate with less nursing staff [12] and in-hospital services [2], which can lead to breakdowns in clinical care pathways, such as a reduced likelihood of patient mobilization on postoperative days 1 and 2 [6]. When staffing is thin, orthopaedic surgeons should take a more active role when rounding to ensure that patients get out of bed and are otherwise following their perioperative care pathway. We also need to pay closer attention when handing off patients to the weekend coverage team so surgeons can appropriately care for patients that underwent surgeries on Fridays. Those of us who own orthopaedic hospitals or are in a position to influence the schedule should improve weekend nurse staffing to reduce complications and increase compliance with postoperative clinical pathways. Wong and Morra [11] have shown how improved weekend staffing pays for itself by reducing the costs of preventable, adverse effects.

Another contributing factor to the weekend effect is that less experienced surgeons and anesthesiologists tend to work on Fridays [1, 10, 14]. Indeed, in my experience, incumbent surgeons generally enjoy the best weekly schedules while new members of surgical groups take whatever surgical days are available, which is often Friday. Research from the UK [8] and Canada [4] shows that this phenomenon is not unique to the US, either. These findings correspond with previous work [9], which found that as a surgeon’s age increased, his or her rates of postoperative complications, readmissions, and mortality decreased in a near-linear fashion. This surgical experience matters for weekend patients, with Ranganathan et al. [7] finding that surgeons in practice for 10 years or less had a more pronounced weekend effect than more experienced surgeons. Pairing less experienced surgeons and anesthesiologists together on a case in which the operative patient will have reduced postoperative nursing care and less access to hospital clinical services during the early postoperative recovery period does seem like a recipe for disaster.

If we are going to proceed with surgeries on Fridays, ensuring adequate staffing is the right thing to do for financial and patient-safety reasons. Taking Fridays off should not be viewed as a reward for seniority when it comes with higher risks for patients, and more experienced surgeons should rethink their surgical schedules accordingly. Additionally, we all need to pay closer attention to staff adherence to perioperative care pathways over the weekends, as well as the hand-offs we make on Fridays.

I know these recommendations place the onus on us, the surgeons, to ameliorate the weekend effect by altering our schedules and increasing our engagement with clinical care pathways, but I do not think hospitals and health systems will significantly increase their spending for adequate weekend coverage. Our patients’ health and safety are ultimately our responsibility, and reconsidering how we divide our surgical time has the potential to protect patients from the weekend effect. Therefore, I believe our best course of action is to increase our weekend supervision of our patients’ care and let less experienced surgeons operate earlier in the week.