Read Full Text: Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care (Free to access!)
Journal: The Lancet (2018 Impact Factor is 59.1)
Year Published: 2016
Ranked 26th on our 2014-2019 list of the 50 most influential articles
Article overview for OTs
We all know how difficult it is to establish best practices for the treatment of a diagnosis in the first pace—but even after best practices have been established, there are more obstacles to overcome in actually implementing them.
One such factor, which can initially seem like a somewhat trivial obstacle, actually plays a significant role in the quality of care that patients receive.
This factor is timing.
This particular article examines the time of day at which a patient is admitted to the hospital—and how this impacts the overall quality of care received.
Two specific temporal effects that this study sought to look deeper into were:
- The “weekend effect” is the association of poorer care quality and outcomes for patients admitted on the weekend versus those admitted during weekdays.
- The “off-hour effect” in which patients admitted outside of usual working hours receive poorer care than those admitted during regular hours.
There is evidence of both of the aforementioned effects in numerous studies looking at varying diagnoses. But the authors of this week’s study postulated that the previous studies might be over-simplifying the effects of time.
This study examined the quality of healthcare received by patients by considering both days of the week and times of day.
Taking this more complex, full-picture view of temporal variation, the study identified four main patterns of temporal variation, when looking at 12 areas of stroke care:
- A diurnal pattern: In other words variations across the time of day. This was not limited to just differences in daytime versus nighttime patterns. It turns out that, for some areas of care, patients admitted in the morning received interventions more quickly than those admitted in the afternoon.
- Day of the week variation: Variations in quality of care do vary from weekdays to weekends. However, it’s interesting to note that, with therapy in particular, patients admitted on Fridays were less likely to receive evals within 72 hours than those admitted on other days of the week.
- A combination of overnights and weekends: There was a pattern in some areas of care for poorer quality being delivered during overnight and weekend shifts.
- Sequential change in quality in both day and time: In some areas of care, areas, showed a sequential pattern of improving across weekdays, then slumping again on weekends.
More details about the study
This study looked specifically at the care delivered to acute CVA patients admitted to hospitals in England and Wales between April 1, 2013 and March 31, 2014.
The cohort was composed of 74,307 patients.
Indicators of quality of care were derived from the UK National Guidelines for stroke care. These indicators included:
- Receiving a brain scan within 1 or 12 hours of admission
- Direct admission to the stroke unit (or ICU) within four hours
- Administration of intravenous thrombolysis with alteplase
- Door-to-needle time of less than 60 min for patients treated with alteplase
- Dysphagia screening within four hours
- Reviews by a stroke specialist physician and nurse within four hours
- Assessments by physiotherapy, occupational therapy, and speech therapy within 72 hours
Please see the article for how the data was controlled to account for variation in individual presentation (i.e. for severity of stroke).
It is worth noting that fatality rates of stroke, although higher during off-hours, were largely able to be accounted for by the severity of the presentation. In other words, patients have a tendency to be more unwell when they are admitted in the evening.
How OT was involved
Assessment by an occupational therapist within 72 hours of admission is one of the standards for stroke care in the UK, and this factor was measured in this study.
For each of the areas of quality of care, the authors used the data to create heat maps of when provision of care was the most variant.
You can see from the chart above that OT was the most variant (least likely to complete evaluation in 72 hours) toward the end of the week, particularly on Fridays. This was true of all three therapy disciplines.
While all three therapy professions showed variation in care toward the end of the week, it is interesting to note (on Table 2 in the article) that of the three disciplines, PT had the smallest coefficient of variation, OT was in the middle, and SLP had the highest degree of variation.
Takeaways for OT
(These are my personal takeaways, and were not mentioned in the article.)
This article contributes to a growing body of literature examining how timing impacts institutional performance, as well as individual performance. This research has been popularized by the book When: The Scientific Secrets to Perfect Timing, which could be a good read if you are interested in learning more about temporal variation.
So, my takeaways are based not only on this article, but also on my own growing awareness of temporal variation.
On a department level, we need to be thinking about how timing impacts our ability to provide the best care possible to our patients
For the patients in this study, those admitted on Fridays were the least likely to receive an OT eval within 72 hours. If you work with stroke patients and follow similar standards, it may be worth looking at this data and thinking about how your OT department is staffed, especially on Fridays.
While this study is specific to acute care and CVAs, the findings can be applied to other settings and diagnoses. These findings can serve as a basis for beginning to think about how time of day and day of week impact the care you are providing. And they certainly make a case for conducting audits of your department’s care.
From a practitioner level, we should be thinking about when our personal peaks and valleys occur throughout the day—and we need to plan accordingly.
This article contributes to a body of literature that indicates we all peak and slump on a natural rhythm throughout the day. To perform your most effective work, it might be worth taking a personal audit of when you are doing your hardest work. You can schedule those times to do your OT evals and treatments, and use your slump times for performing the more meaningful tasks.
From a patient level, we also need to be aware that our patients are going through their own peaks and valleys
It is also important to remember that our patients also have their own natural rhythms, and if we really want to get their peak performance, we should think about timing in when we plan out our days. For example, by and large, it seems that people tend to perform better at 10 am than right after lunch.
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