Send letter to journal:
Re: EMERGENCY DEPARTMENT, WEEKENDS, AND TEMPORAL PATTERN OF OCCURRENCE OF ACUTE MEDICAL DISEASES.

Dear Editor

We read the interesting paper by Miṛ et al [1], who found that in the emergency department (ED) weekends are not characterized by a loss of effectiveness compared to workdays. The possible reduction in staff and loss of attention on weekends is a topic still under debate. A recent study [2] analyzed the six more common urgent procedures usually utilized in acute care hospitals, and found that only 5% of these were performed on the weekend. However, though these procedures are not performed on weekend for scheduled activities, they are promptly available in the case of urgency. In the recent past, traditional estimates of emergency physician have been first based on merely quantistic analysis (volume of patients seen in ED), and successively improved by the utilization of multivariate formulas considering other parameters, eg, lenght to stay, intensity and type of services. However, determination of emergency physician workload derives from several considerations, and it’s not the same to face with a myocardial infarction or a minor trauma .

But the problem is: which kind of urgent diseases are more likely to occur on weekend?

Several studies have shown that weekend time is less likely to be interested by acute cardiovascular events. Myocardial infarction occurrence is increased by approximately 20% on Monday compared with other days of the week [3], and also cardiac arrests are higher on Mondays, with lowest numbers over the weekend [4]. Again, a significant Monday peak in the occurrence of ischemic stroke has been reported as well [5]. It has been speculated that the transition from the quiet life on weekends and the patients’s activity (or change in activity) on Mondays may be responsible for the lower occurrence of myocardial infarction and stroke on Saturday and Sunday and the peak on Monday. This could explain why, despite the possible condition of both reduced staffing and availability of services during weekends, the adjusted odds of death for patients admitted on weekends is only slightly increased (OR: 1.03, 95% CI: 1.01 to 1.06) [6], and suggest a lower severity of cases admitted on weekend. Since acute diseases referring to the hospital respect a temporal pattern of occurrence, it is possible that quantity and quality of ED staffs might take into account the increased demand of specific facilities in certains hours of the day [7] and days of the week as well. Only as an example, it could possible to suggest a “monday-load” staffing pattern for ambulances equipped with high-trained personnel staffs transporting cardiovascular patients. The maximum demand on facilities and professional health expertise may occur during different days of the week and varying depending on diseases itselves.

References

(1) Miṛ O, Sanchez M, Espinosa G, Millà J. Quality and effectiveness of an emergency department during weekends. Emerg Med J 2004;21:573-4.

(2) Bell CM, Redelmeier DA. Waiting for urgent procedure on the weekend among emergently hospitalized patients. Am J Med 2004;117:175-81.

(3) Willich SN, Lowel H, Lewis M, et al. Weekly variation of acute myocardial infarction. Increased Monday risk in the working population. Circulation 1994;90:87-93.

(4) Peckova M, Fahrenbruch CE, Cobb LA, et al. Weekly and seasonal variation in the incidence of cardiac arrests. Am Heart J 1999;137:512-5.

(5) Manfredini R, Casetta I, Paolino E, et al. Monday preference in onset of ischemic stroke. Am J Med 2001;111:401-3.

(6) Cram P, Hillis SL,Barnett M, Rosenthal GE. Effects of weekend admissions and hospital teaching status on in-hospital mortality. Am J Med 2004;117:151-7.