‘Weekend effect’ makes surgery risky for kids

Children who underwent urgent emergency procedures on weekends were 63 percent more likely to die than those treated during the week. Researchers say the next step is to investigate "what, how, and why" is behind the "alarming disparity." (Credit: iStockphoto)

When performed on the weekend, simple emergency surgeries for children are more likely to result in complications or even death, a study shows.

Deaths from hernia repairs, appendix removals, and other such common emergency procedures for kids are very rare, whether Monday through Friday or on weekends, researchers say.


Even so, the marked increase risk at hospitals nationwide on Saturday and Sunday points to a worrisome, unexplained “weekend effect.”

The study calls for an in-depth examination to find any after-hours safety lapses or clinical glitches that need to be addressed.

“Numerically speaking, the number of deaths was quite small, but even a single preventable death is one too many,” says senior investigator Fizan Abdullah, a pediatric surgeon at Johns Hopkins University Children’s Center.

“This demands that we examine any factors that may cause or contribute to such occurrences and find ways to prevent them,”

Miniscule, but troubling risk

The findings, published in the July issue of the Journal of Pediatric Surgery, are based on analysis of surgical records involving nearly 440,000 pediatric admissions nationwide over 22 years. Children who underwent urgent emergency procedures on weekends were 63 percent more likely to die than those treated during the week.

The investigators emphasize that an individual patient’s risk of dying was miniscule and the actual deaths attributable to the weekend effect were very few, just 30 over the 22 years.

Although the study did not explain why weekend effect occurs, the researchers say possible factors include decreased weekend hospital staffing, slower response times, and decreased availability of certain imaging and lab tests.

The investigators compared death and complication rates for some 112,000 children treated on weekends with those for 327,000 patients treated during the week.

More blood transfusions

In addition to higher risk of dying, weekend procedures carried a higher likelihood of surgical complications such as inadvertent wound lacerations or punctures, which suggest clinician error or equipment malfunction either during or after surgery. Children undergoing procedures on weekends were 40 percent more likely to develop such complications.

Weekend patients were also 14 percent more likely to need blood transfusions despite being no more likely than weekday patients to suffer serious blood loss during surgery. The reasons for this elevated blood transfusion risk remain unclear but may be due to post-surgical care.

Blood transfusions, although they can be lifesaving, carry risks, including a higher rate of wound infection due to temporary suppression of a patient’s immune system.

The surgeries examined in the study are considered generally safe and relatively simple and included appendectomies, hernia repairs, draining and cleaning of infected wounds, bone fracture treatment, and surgeries to drain excess fluid in the brain.

Why the disparity?

Overall, cases that showed up at the emergency room on weekends were no more severe than weekday cases, so the conditions themselves did not fuel the higher complication and death risk, researchers say. The disparity in outcomes persisted even after researchers adjusted their analysis to account for any possible differences in disease severity.

“These are provocative findings and, we hope, a conversation starter,” says lead author Seth Goldstein, a pediatric surgery resident at Johns Hopkins. “Our next step is to understand the what, how, and why behind this alarming disparity.”

Johns Hopkins Children’s Center recently launched a program that tracks how children fare in the 30 days after surgery. Data from the program, the researchers say, should help reveal potential vulnerabilities and point to interventions to reduce risk. Such factors may play out differently in individual hospitals, so it is important for each institution to gauge its own weekend outcomes and make adjustments where needed, the investigators say.

“Hospitals must tease out factors such as how many people were there in the OR and ER, how many nurses were on a specific unit, what imaging was done and how soon, and then correlate all these with how well patients do after surgery,” Abdullah says.

Source: Johns Hopkins University