May 12, 2017

Weekend woes

The story

As a resident, you get used to taking blame. And for years experts pinned extra weekend deaths on reduced staffing levels. But what if weekend patients are just sicker?

The background

Your weekend and public holiday admissions are almost 10% more likely to pass away, say a host of studies that rely on administrative data like hospital diagnostic codes for their analysis. It's called the weekend effect, and for years it's worried doctors and hospital administrators. The issue peaked in early 2016, when junior doctors in the UK held strikes in opposition to government contracts that called for higher weekend staffing levels.

The study

Investigators combed through electronic health record data at four academic hospitals in the UK. They found that 30-day mortality was 9% higher for patients admitted on weekends and public holidays, in keeping with prior studies. But by looking at common lab markers like blood counts, electrolytes, and inflammatory markers, they found that weekend patients were substantially sicker than their weekday counterparts. The severity of illness at presentation, as estimated by lab markers, explained as much as half of the excess mortality seen on weekends.

The takeaway

A look under the hood shows that the weekend effect is as much about patients as it is about staff. Since the lab data used in this study was pretty basic, further studies that use blood gases or illness severity indexes could help.

Say it on rounds

When you want to watch the Warriors, but your patient needs a rectal exam

Not all tasks can be done remotely yet, even if the future is promising. A virtual glucose management system in which three remote diabetes providers submitted insulin recommendations via notes in patients' electronic charts reduced hyperglycemia (blood glucose > 225) by 39% and hypoglycemia (glucose < 75) by 36% in a single center cross-sectional study. The virtual system did not change the number of inpatient diabetes consults.

When the clinical documentation department flags your progress note

Surveillance helps, even for a stud like you. A review of FDA approvals between 2001 – 2010 found post-market safety events in 32% of new drugs, including withdrawals, black box warnings, or clinical safety memos. Accelerated approvals were among the most frequent offenders, as were biologics and psych meds. Median time to a safety event was 4 years.

When the echo techs have the weekend off

Sometimes all you have is your calculator. In the case of acute pulmonary embolism (APE), that may be enough. A look at 500 patients with APE confirmed by CT angiogram found that a blood pressure index (BPI) obtained from dividing the systolic blood pressure by the diastolic blood pressure was sensitive and specific for right ventricular dysfunction, a heavy contributor to APE-related death. BPIs < 1.4 were highly predictive of mortality.
Am J Emerg Med

Brush up

More than a rash

Mix the wrong drug with the wrong patient and the combination can be explosive. Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome are the main players in severe cutaneous adverse reactions to drugs. All are life-threatening and can lead to severe sepsis. Look for skin eruptions on the face and upper trunk in SJS-TEN, while DRESS has flu-like prodromal symptoms that precede eruption. Stopping the offending agent – here's a list of common culprits in SJS – is critical.

What's the evidence

For early drug withdrawal in severe adverse cutaneous reactions? A 10-year observational study of ICU patients with SJS or TEN found that patients who had the causative agent stopped early (before definitive evidence of SJS) were half as likely to die as those who had the drug withdrawn late (after definitive signs of SJS or TEN). The findings highlight the importance of recognizing systemic drug reactions and taking prompt action.

What your health policy friends are talking about

Health insurance is complex, even (or especially) for med school grads. Here's an article on Ryan Lewis, a 2-year-old born with esophageal atresia, that frames the preexisting conditions political debate in a practical context.

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