Hospital deaths and weekend admissions--how do we leap across a chasm?

91 Clinical Nurse SpecialistTM Copyright © 2002 by Lippincott Williams & Wilkins, Inc. T concept of a chasm is somewhat compelling and is the one chosen by the Committee on the Quality of Health Care in America to describe the distance between what exists today and what we need to achieve in improving the quality of healthcare. In a recently released landmark report, Crossing the Quality Chasm,1 the Committee on the Quality of Health Care in America’s thoughtful analysis is undergoing rapid dissemination among healthcare leaders in the United States and can provide direction for clinical nurse specialists who are committed to improving safety systems and patient outcomes. This same committee also developed an excellent first report, To Err is Human: Building a Safer Health System,2 which has educated us that tens of thousands of Americans die each year from errors in their healthcare, and hundreds of thousands suffer or barely escape from nonfatal injuries that a truly high-quality care system would largely prevent.2 A somewhat disturbing study that highlights the needs for safer and higher quality systems of care3 was recently published in a leading medical journal, based on a 10-year study of almost 3.8 million hospital admissions. Researchers in Canada studied every patient case admitted to an acute care hospital through the emergency department between April 1, 1988, and March 31, 1997, and compared patient in-hospital mortality among patients admitted on weekends with those admitted on weekdays. The weekend was defined as the period from midnight on Friday to midnight on Sunday. Three prespecified primary diseases were studied (ruptured aortic aneurysms, acute epiglottitis, and pulmonary embolism), as well as 3 control diseases (myocardial infarction, intracerebral hemorrhage, and acute hip fracture). They selected the primary diseases based on certain criteria, including conditions that have a high mortality and rapid death, but are treatable with the critical time of treatment being the first few days of hospitalization. They also chose conditions in which patients receive a substantial amount of care in clinical settings other than a critical care unit or the emergency department. Their belief was that the fluctuations in staffing levels are minimal in critical care settings compared with non–critical care areas. The 3 control diseases selected for comparison included conditions that did not meet the same criteria: acute myocardial infarctions are usually managed in critical care settings, acute intracerebral hemorrhage treatment is generally unavailable, and acute hip fractures are often treated more promptly on weekends because operating rooms are more available than on weekdays. The surprising findings showed that patients in all 3 primary diseases were more likely to die in the hospital if they were admitted on a weekend compared with a weekday—ruptured aortic aneurysm (P = .001), acute epiglottitis (P = .04),