NHS England – Evidence Base for 7DS Dr Andrew Stein, NHS England 7 Day Forum Member,

Consultant in Renal and General Medicine, UHCW,

Coventry

BBC FOI Study – March 2014

• In England, 86 Consultants in hospital on a

Wednesday

• 8 on Weekend Day

• Wednesday 4 December 2013, and the Weekend of 7

and 8 December

• Weekend is nearly 30% of week

Structure of Talk

• Evidence for 7DS

• Mortality

• 10 Clinical Standards

• Potential benefits

• 7 Day Forum

Arguments for 7DS

1. Mortality

2. Junior health professional supervision – Weekend is nearly 30% week

– Would you let a first year pilot fly a Jumbo in 30% week?

3. Monday chaos (hospital, GP and social) – 4h/12h = performance manage a nearly broken system that is unstainable

(financially)

– £2100 per patient pw acute

– £750 pw nursing home, £500 care home,

– £350 pw domiciliary care 4 x 1 hour per day

4. Its right, in a civilised society

Mortality Data

UHCW Yesterday

• 563 attendances to ED

• 119 admitted

• 101 4h breaches (81.5%)

“Houston .. we (still) have a problem”

Unselected Patients - Cohort Studies (1)

• All admissions, 2012. 14,217,640 pts Freemantle, Keogh, Pagano et al

• All emergency admissions, 2010. 4,317,866 pts Aylin P et al

• Cardiac arrest, 2008. 58,593 pts Pederby MA et al

• ED, 2014. 539,122 pts Concha OP et al

• ED, 2013. 4,225,973 pts Sharp AL et al

• ED, 2012. 5,271,327 pts Handel EH et al

• ED, 2004. 641,860 pts Cram P et al

.. 10-15% Increase in Mortality

Unselected Patients - Cohort Studies (2)

• Elective surgery, 2012. 11,535,267 pts Mohammed MA et al

• Elective surgery, 2013. 4,133,346 pts Aylin P et al

• Internal medicine wards, 2010. 429,880 pts Marco J et al

• ITU, 2008. 20,466 pts Laupland KB et al

• ITU, 2002. 156,136 pts Barnett MJ et al

Elective Surgery P Aylin et al, BMJ, 2013

• Setting All acute and specialist English hospitals carrying out elective surgery over three financial years, from 2008-09 to 2010-11.

• Participants Patients undergoing elective surgery in English public hospitals.

• Main outcome measure Death in or out of hospital within 30 days of the procedure.

• Results There were 27,582 deaths within 30 days after 4,133,346 inpatient admissions for elective operating room procedures .. the adjusted odds of death were 44% and 82% higher, respectively, if the procedures were carried out on Friday (odds ratio 1.44, 95% confidence interval 1.39 to 1.50) or a weekend (1.82, 1.71 to 1.94) compared with Monday.

• Conclusions The study suggests a higher risk of death for patients who have elective surgical procedures carried out later in the working week and at the weekend.

Selected Cohort Studies

• Cardiology (AMI, Aortic rupture, Heart failure)

• Gastroenterology (Upper GI bleed, non-variceal)

• Nephrology (AKI, Maintenance HD)

• Neurology/neurosurgery (ICH, CVA, Traumatic brain injury)

• Orthopaedics (#NOF)

• Other (Opiate overdose)

• Paediatrics (Weekend birth)

• Respiratory (COPD, PE, Pneumonia)

Haemodialysis Sakhuja et al. AJKD

SETTING & PARTICIPANTS:

• Nonelective admissions of adult patients (≥18 years) on maintenance dialysis therapy (n = 3,278,572)

RESULTS:

• 704,491 admissions over weekends versus 2,574,081 over weekdays. Unadjusted all-cause in-hospital mortality was 40,666 (5.8%) for weekend admissions in comparison to 138,517 (5.4%) for weekday admissions (P < 0.001). In a multivariable model, patients admitted over weekends had higher all-cause in-hospital mortality (OR, 1.06; 95% CI, 1.01-1.10) in comparison to those admitted over weekdays and higher mortality during the first 3 days of admission (OR, 1.18; 95% CI, 1.10-1.26). Patients admitted over weekends were less likely to be discharged to home, had longer hospital stays, and had shorter times to death compared with those admitted over weekdays on adjusted analysis.

CONCLUSIONS:

• Maintenance dialysis patients admitted over weekends have increased mortality rates and longer lengths of stay compared with those admitted over weekdays

No Evidence for Higher Weekend Mortality

• SAH

• Upper GI bleed (variceal)

• Sepsis

• Paed/neon ITU

• Laparoscopic appendectomy

• Liver Transplantation

• Trauma

Other Factors Increasing Mortality

• Mondays Maggs, 2010

• Nursing levels, occupancy, W/E + influenza Schilling, 2010

• ITU Discharge at night Laupland, 2008

• ITU Discharge at W/E, and Mons, Fris Rollins, 2002

• Cons presence Acute Medicine Bell, 2013

• Trainees Ricciardi, 2014, 48,253,968 pts

How do we know its real (1)?

• All countries – UK, USA, Australia, others

• All systems – Public, private and public-private

• Coincidence 10-15%?

• Emergency and Elective

• All stages of admission – ED, gen med, ITU, specialist ward etc

• All ages

• 50 million+ patients studied

How we know its real (2)?

• Medical and Surgical

• Elective Surgery – Risk increases Thurs and Fri

– Ie failure to rescue towards end of week, and w/e

– Even for low risk ops

• Teams that normally provide 7D care – Eg nephrology, CCU, ITU, Labour Suite

– Also have a problem

– Tells us alot

• So, may take a very big hammer to sort – ie not just a doc problem

NHS Services, Seven Days a Week Forum

• Chair: Sir Bruce Keogh

• Supported by Professor Keith Willett

• 22 members, met monthly meetings in 2013

• 5 Subgroups: clinical standards (Celia Ingham-

Clark), commissioning (Mark Spencer), finance

(Tony Whitfield), workforce (Raj Bhamber), service

providers (Mark Hackett)

• Urgent and emergency care and supporting

diagnostics

• Ten clinical standards

Publication of Initial Findings Dec 2013

http://www.england.nhs.uk/wp-content/uploads/2013/12/forum-summary-report.pdf

The Forum’s proposals for …

• 10 standards, describing the minimum

standards of care patients should

expect to receive 7DW

• use of contractual and other levers

• broadening the Forum’s remit in 2014

… were accepted in full by NHS England’s

Board.

Summary of Initial Findings

• Ten standards for commissioners • Mixture formal, contractual and informal levers required • Workforce framework • A rapid expansion of 7DS everywhere would be expensive and

impractical • 7DS ≠ 7DW all staff, 7 Days • But, ‘everyone must do something’ • In the longer term, 7DS are likely to support the case for

consolidation of some hospital services on fewer sites

Conclusions

Conclusions

• There is overwhelming evidence of a ‘Weekend Effect’

• Ie you are more likely to die, during an emergency or

elective admission over weekend, all countries, all

ages

• This may reflect ‘failure to rescue’ by the health and

social community (1°, 2° and social care)

• 10 NSHE Clinical Standards in Acute Trusts – a start

• Only whole system change will reverse it

Big Big Question: Answer

• Do we want to unblock our hospitals, EDs ‘place of

safety, where lights are on’ and parts of the bed base has

become a large barn for the frail elderly?

• Otherwise 4h/12 trolley waits will continue

= performance manage a half-broken health and social

care system

• Question: What needs to change?

• Answer: ‘Yes. It’s the whole system stupid’

• I would say the ‘no change’ option is not acceptable in a

civilised society, or the world I want to live in

• What sort of world do you want to grow old in?

Thankyou

Ideas welcome NHSE 7DS

andrew.stein@uhcw.nhs.uk