Leukemia Admissions on Weekends Result in Longer Hospital Stays

Jenni Laidman

August 27, 2014

Children with newly diagnosed leukemia admitted to the hospital on the weekend stayed in the hospital nearly a day and a half longer than children admitted during the week, and were at 1.5 times the risk for respiratory failure, according to a study published online August 25 in JAMA Pediatrics.

"This has implications for the way we staff our pediatric oncology units," said senior researcher Richard Aplenc, MD, PhD, associate professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania and section chief for hematologic malignancies in the division of oncology at The Children's Hospital of Philadelphia.

"We should have the same resources on the weekend as we have during the week, and potentially even more," Dr. Aplenc told Medscape Medical News. "The data clearly show that patients who come in on the weekend are more ill than patients who come in during the week." In fact, weekend patients were "significantly more likely to require ICU-level care within the first 2 days of index admission" than patients admitted during the week (4.8% vs 3.1%; < .001), he reported.

In their retrospective cohort study, Dr. Aplenc and colleagues assessed leukemia admissions from 1999 to 2011 at 43 children's hospitals in 17 major metropolitan areas, accounting for 85% of all admissions to freestanding children's hospitals in the United States.

They analyzed the records of 12,043 children in the Pediatric Health Information System database — 10,720 with acute lymphocytic leukemia (ALL) and 1323 with acute myeloid leukemia. Of those patients, 2009 (16.7%) were admitted on the weekend.

There was no association between weekend pediatric leukemia admission and increased mortality (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.8 to 1.6), as there is in adult leukemia admission. However, children whose initial admission was on the weekend stayed in the hospital an average of 1.4 days longer than those admitted during the week (95% confidence interval [CI], 0.7 - 2.1), waited 0.36 days longer for chemotherapy (95% CI, 0.3 - 0.5), and had a higher risk for respiratory failure (OR 1.5; 95% CI, 1.2 - 1.7).

The data were adjusted for disease, sex, age, race/ethnicity, insurance, severity of illness at admission, and hospital factors, such as the presence of a fellowship program, magnet status, the percentage of public payers per admissions per hospital year, and the number of oncology admissions per year.

Respiratory failure, a common complication in patients with newly diagnosed leukemia, appears to be less well managed in children admitted on Saturday or Sunday, the researchers write. However, the delay in time to chemotherapy, which the study also uncovered, might not be clinically relevant; it is less than a day and a previous study showed no adverse outcomes from delayed chemotherapy in children with ALL (J Pediatr Hematol Oncol. 2012;34:e8-e11), they report.

Dr. Aplenc said he can only speculate why there is an increase in patient acuity on weekends. "That is, for us, a future direction," he said.

This study underlines the need for each hospital to become "a true 24-hours-a-day 7-days-a-week operation all year," writes Patrick J. Hagan, MHSA, an independent management consultant and former president and chief operating officer of Seattle Children's Hospital, in an accompanying editorial.

The best solution isn't simply adding more staff on the weekend, he notes, but changing the ways hospitals do business across the board by scheduling elective surgery throughout the week, not just on weekdays.

Hagan acknowledges that such a solution would demand a huge culture shift, but thinks its benefits would be significant.

"Because we don't have a steady state, we necessarily have peaks and valleys," Hagan told Medscape Medical News. "Future costs, in particular, could be saved if we leveled out the type of activity we have day to day. When you see hospitals as big as they are, and parking decks as big as they are, they're that big because of how busy the hospital is on Wednesday and on Thursday. On weekends, those parking decks in many areas are empty," he explained. Scheduling elective procedures 7 days a week could potentially reduce the call to increase the number of beds, operating rooms, and staff, while improving patient outcomes, he said.

Hagan notes that studies have shown that patient risk rises when patients are admitted on weekends, holidays, and in early July.

As a less drastic step, Hagan proposes that hospitals ensure that clinical protocols are being followed on the weekends. "We are not rigorous. We are not disciplined," he told Medscape Medical News. "We're trying to get there."

"What this study highlights is that even in pediatric cancer care —probably the highest order in the nation of protocol-driven care — if somebody isn't admitted on a weekday, it's likely that their care will be different," Hagan said.

Study coauthor Brian T. Fisher, DO, MSCE, from The Children’s Hospital of Philadelphia, reports receiving research funding from Pfizer unrelated to this research.

JAMA Pediatr. Published online August 25, 2014. Abstract, Editorial


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