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Abstract
Background In 2013, the English National Health Service launched the policy of 7-day services to improve care quality and outcomes for weekend emergency admissions.
Aims To determine whether the quality of care of emergency medical admissions is worse at weekends, and whether this has changed during implementation of 7-day services.
Methods Using data from 20 acute hospital Trusts in England, we performed randomly selected structured case record reviews of patients admitted to hospital as emergencies at weekends and on weekdays between financial years 2012–2013 and 2016–2017. Senior doctor (‘specialist’) involvement was determined from annual point prevalence surveys. The primary outcome was the rate of clinical errors. Secondary outcomes included error-related adverse event rates, global quality of care and four indicators of good practice.
Results Seventy-nine clinical reviewers reviewed 4000 admissions, 800 in duplicate. Errors, adverse events and care quality were not significantly different between weekend and weekday admissions, but all improved significantly between epochs, particularly errors most likely influenced by doctors (clinical assessment, diagnosis, treatment, prescribing and communication): error rate OR 0.78; 95% CI 0.70 to 0.87; adverse event OR 0.48, 95% CI 0.33 to 0.69; care quality OR 0.78, 95% CI 0.70 to 0.87; all adjusted for age, sex and ethnicity. Postadmission in-hospital care processes improved between epochs and were better for weekend admissions (vital signs with National Early Warning Score and timely specialist review). Preadmission processes in the community were suboptimal at weekends and deteriorated between epochs (fewer family doctor referrals, more patients with chronic disease or palliative care designation).
Conclusions and implications Hospital care quality of emergency medical admissions is not worse at weekends and has improved during implementation of the 7-day services policy. Causal pathways for the weekend effect may extend into the prehospital setting.
- emergency department
- health policy
- health services research
- medical error
- measurement/epidemiology
- quality improvement
Data availability statement
Data are available on reasonable request. We are willing to share our data for collaborative research.
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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- emergency department
- health policy
- health services research
- medical error
- measurement/epidemiology
- quality improvement
Data availability statement
Data are available on reasonable request. We are willing to share our data for collaborative research.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Collaborators The HiSLAC Collaboration Case Record Reviewers: Randeep Mullhi, Jonathon Coates, Neil Patel, Emma Carver, Zoe Kimbley, Nicholas Price, Akshay Nair, Sheena Sikka, Navinee Gilliat, Greg Packer, Anna Blackwell, Emma Christmas, Adebola Adebowale, Sebastien Ellis, Rebecca Mallinson, Farhad Peerally, Daniel Forster, Simmi Krishnan, Vishal Patil, Richard Hopkins, Ruth Todd, Sofia Cavill, James Murray, Imran Ghafoor, Katey Flowers, Paul Dean, Christopher Wright, Shreena Shah, Jonarthan Thevanayagam, Richard Hunt, Karwai Tsang, Mohammed Yusuf, Mark Whitsey, Brian Hogan, Amina Jaffer, Emma Bryden, Alison McInerny, Rebecca Powell, William Wareing, Yasir Elhassan, Parijat De, Manoj Viegas, Christopher Wharton, Michael Duffy, Richard Heinink, Chris Beet, Elin Roddy, Anna Szczerbinska, Annabel Makan, Manohasandra Majuran Manohasandra, Neel Patel, Behrad Baharlo, James Brown, Jun Jack Wong, Salmaan Mughal, Musarat Hussain, Nick Murch, Georgina Barrows, Ryan Boyle, Syed Habib Zaidi, Ivan Collin, Caroline Kibbler, Monica Bowa-Nkhoma, Clare Hughes, Muniswamy Hemavathi, Thomas Cozens, Khin Nyo, Debbie Beck, Claire Peplow, Devasena Subramayam, Tom McLellan, Gautam Bagchi, David Hartin, Stewart McMorran, Chung Thong Lim, Hiba Mohamed, John Ong, Hoi-Ping Mok, Ayesha Khaliq, Abigail Ford. Local project leads in each of the 20 hospitals: Professor Mark O’Donnell, Dr Chris Adcock, Dr Paul Peter, Dr Nnenna Osuji, Dr Emma Rowland, Dr William Bernal, Dr Mehool Patel, Dr Jayachandran Radhakrishnan, Dr Emma Vaux, Dr Rupert Negus, Dr Stuart Henderson, Dr Andrew Gibson, Dr Richard Heinink, Dr Hassan Paraiso, Dr Earl Williams, Dr Lee Dowson, Dr Sanjiv Jain, Dr Mike Berry, Dr Catherine Snelson, Dr Becky Thorpe, Dr Emma Redfern, Dr Emma Rowlandson.Oversight And Governance Committee: Michael Rawlins (Chair), Jennifer Dixon, Peter Lees, Paddy Storrie, Alastair Henderson, Matt Sutton and Naomi Fulop.
Contributors JB: developed the original design and contributed to methodology development, analysis of data and writing manuscript. CA: data collection, methodology development, analysis of data and contribution to writing manuscript. AJG, GR and JS: data collection, methodology development, analysis of HES data, statistical analysis and contribution to writing manuscript. CT devised and led on the qualitative research design, analysis and writing of the manuscript; ES was involved in the design and together with JW contributed to organising and facilitating the focus groups and interviews, analysis and writing of the manuscript. RL: writing of the application, design of the project, health economics analysis and contribution to writing of manuscript. SIW developed the statistical methodology for the cost-benefit analysis and together with JL conducted health economics analysis and contributed to writing of the manuscript. CB: methodology development, development of case record review and reviewer training materials and contribution to writing manuscript. AB: data collection, methodology development and contribution to writing manuscript. Y-FC: systematic review, methodology development and contribution to writing manuscript. MC, TH, RM, PR, CR and MT: methodology development and contribution to writing manuscript. LR: collaborator engagement, dissemination of findings and contribution to writing manuscript.
Funding This study was funded by Health Services and Delivery Research Programme (Grant number: https://fundingawards.nihr.ac.uk/award/12/128/17).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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