Weekend and holiday admissions to hospital increase risk of
21 Dec 2010
Patients treated by Welsh hospitals for upper gastrointestinal
(GI) bleeding were 41% more likely die if they were admitted on a public
holiday and 13% more likely if it was at the weekend, according to
research by the Department of Public Health at the University of Oxford.
The findings are published in the January issue of Alimentary
Pharmacology and Therapeutics.
Upper gastrointestinal bleeding, which can be caused by
conditions such as peptic ulcers and gastritis — an inflammation of
the stomach lining often caused by alcohol — results in
approximately 25,000 hospital admissions a year across the UK. The
highest rates reported are in Scotland, with the lowest rates often
in southern England.
Researchers who analysed the records of 22,299 people admitted a
total of 24,421 times between 1999 and 2007 also found that
admissions, but not death rates, were significantly influenced by
“The higher death rates for weekend and public holiday admissions
could not be explained by differences in the patients admitted and
may be down to reduced staffing levels or delays in investigative
procedures such as endoscopy” says study lead Dr Stephen Roberts
from the School of Medicine at the University of Swansea, UK.
Key findings of the study include:
- The overall incidence of upper GI bleeding was 134 per
100,000 of the population, with a higher incidence in males than
female (153 versus 117). Incidence rates increased sharply with
age, from 52 per 100,000 in people aged 18 to 24 to 774 for
those aged 85 plus.
- People living in the most socially deprived areas of Wales
were twice as likely to be admitted for GI bleeding as people
living in the least socially deprived areas.
- However, those local authority areas with the highest
incidence of bleeding often had the lowest death rates. This
could be explained by case mix differences, variations in
hospital admission thresholds for less severe cases and less
effective out-of-hours services provided by family doctors in
- Patients admitted on Fridays and Saturdays were
significantly less likely to receive endoscopy than those
admitted on other days and those that did receive this
investigative procedure faced a longer, median wait of three
days. Rates of endoscopy on the day of admission were lower on
Saturdays and Sundays.
- Patients admitted at the weekends and on public holidays
tended to be significantly younger than those admitted during
the week. They had shorter lengths of stay — indicating less
severe bleeds — but similar levels of other health issues.
- Over the whole study period, 10% of people died within 30
days of being admitted to hospital, ranging from 0.2% of people
aged from 18 to 24 to 20.9% of those aged 85 plus.
- Death rates fell significantly during the period studied,
from 11.4% in 1999/2000 to 8.6% in 2006/7.
- When the death rates were adjusted for differences in age
and gender, they were 13% higher at weekends and 41% higher on
public holidays. The difference remained significant even when
the researchers adjusted them to take into account other major
illnesses such as cancer, diabetes, heart disease and organ
- The researchers found no difference in death rates at
weekends and public holidays between hospitals that did and did
not have a formal out-of-hours endoscopy service. However, this
finding is inconclusive as informal services are provided on an
ad hoc basic in many other hospitals.
Dr Roberts says there are a number of possible explanations for
increased deaths at weekends and on public holidays. These could
include reduced staffing levels that may lead to:
- less thorough assessment;
- lack of specialist or senior consultant cover;
- lower levels of multidisciplinary team care;
- poor communication at handover; and
- possible delays in investigations such as endoscopy.
“It is very clear from our research that further studies are
needed to understand why death rates are much higher at weekends and
on public holidays than during the week,” concludes Dr Roberts.
Professor Jon Rhodes, President of the British Society of
Gastroenterology and an associate editor of the Journal, comments:
"The publication of this paper is very timely because the BSG has
been co-drafting a report prompted by concerns raised by the
National Patient Safety Agency about deaths from GI bleeding. This
will suggest that smaller hospitals form networks to provide
seven-day endoscopy cover.
"The Welsh study shows, however, that this alone may not be
sufficient and our society is also pushing hard to promote seven-day
consultant cover in hospitals for the major acute specialties,
Fellow associate editor Dr Brian Fennerty, President of the
American Society for Gastrointestinal Endoscopy, adds: “Sick
patients do not always conform to an 8am to 5pm, Monday to Friday
work schedule and physicians and facilities caring for patients need
to be able to provide the same level of care 24 hours a day, seven
days a week for acutely ill individuals.
"These data implicate our current healthcare systems as being
inadequate for managing acute GI haemorrhage outside of normal hours
and call for an analysis as to why the process of care breaks down
and what needs to be done to fix it.”