When I was a resident, I always marvelled at how on nights and weekends, remarkably fewer people were “required” to take care of patients than on weekdays during work hours. Logic dictated that either people must be receiving substandard care on off hours, because there were fewer personnel, or else perhaps those extra people weren’t necessary. It is possible that neither of these things are true. It may be that the extra people help with a lot of care that happens during the day but isn’t necessary at night. If forced to consider that either substandard care or overstaffing is true, though, the former is a greater concern. It’s not good to be spending money on unnecessary staff, but if patients are receiving substandard care, that’s an issue that needs immediate fixing.
Previous studies have shown that prehospital and in-hospital cardiac arrests in adults show worse outcomes when patients arrest at night than during the day. A prehospital study of children showed similar results. Recently, a study in JAMA Pediatrics looked at survival rates of pediatric in-hospital cardiac arrests at night and during the weekend. Almost 6000 children in hospitals receive CPR each year.
Researchers pulled data from the American Heart Association’s Get With the Guidelines-Resuscitation registry from 2000 through 2012. They found more than 12,400 cases of kids who received CPR for at least 2 minutes in 354 hospitals. They used multivariable logistic regression to look at how the time of the arrest correlated with survival to discharge, after adjusting for a number of variables. These included age, first documented rhythm during the arrest, the location of event in hospital, hypotension, and more.
More than 70% of the children had a return to circulation that lasted at least 20 minutes. More than half (58.4%) survived to 24 hours, and more than a third (36.2%) survived to discharge. After adjusting for potential confounders, researchers did find that the rate of survival to discharge was lower when the arrest happened at night than during the day (aOR 0.88, 95% CI 0.80-0.97). They did not find a difference between weekends and weekdays (aOR 0.92, 95% CI 0.84-1.01).
This is concerning for any number of reasons. The first is because they aren’t the first to show that children might be at higher risk at night. Critically ill children admitted to intensive care units at night, and newborns who require resuscitation at night, are also at higher risk.
This study didn’t include all hospitals, and it’s possible for selection bias to be at work. It’s also possible there have been changes over this period of time to lessen these risks, such as more in-house staff at nights. Other outcomes might be important besides survival to discharge. Most important, we can’t tell why these differences exist.
But it appears that care may be different at nights than it is during the day. It appears that these differences may have significant effects. This study adds to the literature showing this difference isn’t rare. At some point, it’s likely we are going to have to address it.