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Study: MI mortality rate higher on the weekends
'Gold standard' treatments not often provided
A new study in The New England Journal of Medicine formally confirms what many ED managers already know: Patients who are admitted to the ED on the weekends do not receive the same level of care as those admitted during the week.1 In fact, the study shows, mortality at 30 days was significantly higher for patients admitted on weekends (12.9% vs. 12.0%), and these patients were less likely to undergo invasive cardiac procedures, especially on the first and second days of hospitalization.
"In other words, about one in 100 patients suffering their first heart attack on a Saturday or Sunday may be dying unnecessarily," says William J. Kostis, PhD, lead author of the article and a fourth-year medical student and a researcher in the Department of Medicine at the Robert Wood Johnson Medical School in Piscataway, NJ. In the critical day of admission and the day following, patients treated on the weekend during the last four years were one-third less likely than weekday patients to get a percutaneous coronary intervention (PCI), which is one of the American Hospital Association and American College of Cardiology standards for best treatment.
These findings are not a surprise, says Todd Taylor, MD, an emergency physician in Nashville, TN, and an officer of the American College of Emergency Physicians. "In fact, I've been saying these things in lectures I have given," Taylor says. This article, among others, he says, shows that whether you survive a heart attack now depends more on the time of day, the day of the week, and the type of insurance you have, more than on any other factor.
Why the difference?
What causes this variation in care? "It may be due to a difference in the availability of cardiologists and cath labs, which are necessary for all appropriate procedures to be done," offers Kostis.
Taylor agrees. "We know how to treat heart attacks," he says. "The problem is we do not possess all of the resources to do what we need to do on weekend." Clearly, it is the availability of the types of specialists needed to provide the most effective treatment for acute myocardial infarctions (MIs), he says.
There are other therapies that can be delivered, he notes, but they are not as effective as primary angioplasty. "When you have a heart attack, if they take you to the cath lab, open you up and put a stent in, that has been shown to be the most effective treatment," he observes.
Basically, he says, three things are needed to make such procedures possible: A cardiac catheterization lab that can do interventional procedures; nursing and other staff who are available in a short time frame; and a specialist — typically an interventional cardiologist.
Why aren't they available on weekends? "The primary reason is the cost of having, maintaining, and staffing a cath lab that is available 24/7," Taylor says. "Beyond that, it becomes a bit more of an organizational issue."
In some regions, he says, there just aren't enough interventional cardiologists to make one available to every facility that needs one.
One of the potential solutions is managing resources on a regional basis, as the Institute of Medicine recommended in its landmark study on emergency medicine published last summer, Taylor says. But this is clearly something that is decided and organized at a level far above that of the individual ED and its manager.
What can an ED manager do in his or her facility to help improve weekend care for heart attack patients? "An individual ED manager can make a very strong argument from a financial perspective," Taylor says. "Cardiac care, for most major hospitals, pays well — like orthopedics."
Having appropriate staff on hand for weekends would pay for itself, Taylor argues. The biggest challenge an ED manager will face, however, is the desire of upper management to tweak the budget. "They may, for example, look at the number of heart attacks, see that between 1 a.m. and 7 a.m., there are not that many, and decide not to pay to have physicians on call after midnight," he says. "But when you put up a big red sign that says 'emergency,' and then you make ill and injured people wait, bad things will happen: Patients will suffer, the ED staff will suffer, and ultimately patients will get discouraged and leave and/or staff will quit."
Thus, Taylor warns ED managers, do not accept half a solution. "Unless you get a commitment from administration to have an interventional cath lab 24/7 with support cardiologists, don't allow them to force you into calling yourselves a 'cardiac center,'" he says. Bad patient care in such a situation could get the hospital sued, he warns. "Besides," he concludes, "coming in Wednesday and getting one type of care, then getting another type on Saturday is not only not right, but some might call it unethical. Ultimately, some lawyer may end up convincing you you're not right."
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